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FIG.    I.       GIANT   CELL,    ANTERIOR   CENTRAL. 

FIG.    2.       PYRAMIDAL    CELL,    3D    LAYER    INFERIOR    PARIETAL. 

FIGS.    3,    4,    5.       SMALL    PYRAMIDAL    CELLS,    2D    LAYER. 

FIG.    6.      SPINDLE    CELL,    4TH    LAYER. 

FIG.    7.       NEUROGLIA    CELL. 


TEXT-BOOK 

OF  4jy* 

Nervous  Diseases 


BEING   A   COMPENDIUM 


FOR    THE    USE    OF 


Students  and  Practitioners  of  Medicine 


CHARLES   L.  DANA,  A.M.,  M.D. 

Professor  of  Nervous  Diseases  in  Cornell  University  Medical  College  ;  Visiting  Physician  to  Bellevue 
Hospital ;  Neurologist  to  the  Montefiore  Hospital ;  ex-President  of  the  American  Neuro- 
logical Association  ;  Corresponding  Member  of  the  Socicte  de  Neurologie,  etc. 


ffiftb   E&ition 


WITH    TWO    HUNDRED   AND    FORTY-FOUR    ILLUSTRATIONS 


NEW  YORK 

WILLIAM    WOOD    AND    COMPANY 
MDCCCCI 


Copyright,  1901, 
BY  WILLIAM    WOOD   &   COMPANY. 


PRESS   OF 

THE    PUBLISHERS'   PRINTING   COMPANY 

82-34   LAFAYETTE    PLACE 

NEW    YORK 


PREFACE. 


It  is  the  object  of  the  author  in  this  treatise  to  present  the  sci- 
ence of  neurology  in  a  concise  yet  as  far  as  possible  complete  form. 
Each  subject  has  been  taken,  all  the  available  facts  regarding  it 
have  been  ascertained,  the  writer's  own  experience  has  been  col- 
lated, and  with  the  data  thus  gathered  the  chapters  have  been  writ- 
ten. The  labor  involved  in  such  a  task  has  been  very  great,  but  I 
am  encouraged  to  believe  that  the  result  will  be  a  useful  one ;  for 
the  work  does  not  compare  or  compete  with  the  large  treatises 
which  are  already  in  the  field  nor  with  the  smaller  introductory  text- 
books. I  have  tried  to  furnish  a  book  which  will  be  suitable  for 
the  student  and  practitioner  and  not  valueless  to  the  specialist. 

The  extreme  importance  of  a  knowledge  of  anatomy  has  led  me 
to  pay  especial  attention  to  furnishing  in  a  condensed  form  the  most 
recent  accessions  to  our  knowledge  of  this  subject.  Starting  with 
the  facts  that  can  be  gained  in  ordinary  anatomical  works,  the  stu- 
dent can,  I  believe,  acquire  a  good  idea  of  modern  neuro-anatomy 
with  the  help  of  the  anatomical  chapters  given  here. 

In  the  classification  of  nervous  diseases  and  the  description  of 
their  pathology,  I  have  tried  to  apply  the  modern  knowledge  of 
general  pathology  as  modified  by  bacteriology.  This  I  have  done 
conservatively,  yet  not  less  than  in  my  opinion  is  absolutely  de- 
manded. A  good  deal  of  havoc  will  be  wrought  eventually  in  our 
conception  of  the  nature  of  nervous  diseases  by  the  newer  patho- 
logical doctrines;  I  have  made  as  little  change  as  was  consonant 
with  undeniable  facts. 

The  limits  placed  upon  me  have  made  it  impossible  to  furnish  a 
bibliography  ox  to  give  due  credit  to  every  original  investigator. 
Full  references  to  literature  are  to  be  found  in  the  works  of  Hirt, 
Erb,  Seeligmuller,  Ross,  and  Growers. 

In  many  topics  I  have  been  much  helped   by  valuable  mono- 

41GJ J;] 


IV  PREFACE. 

graphs  of  my  American  colleagues.  While  a  part  of  these  are 
credited  to  their  proper  source  in  the  text,  I  feel  that  I  ought  to 
refer  here  to  some  of  the  articles  that  have  been  of  special  service 
to  me.  They  include  monographs  on  Spinal  and  Brain  Tumors  by 
Mills  and  Lloyd ;  on  Cerebral  Palsies  of  Children  by  B.  Sachs ;  on 
Muscular  Dystrophies  and  Writer's  Cramp,  by  G.  W.  Jacoby  and 
by  M.  Lewis;  on  Aphasia,  Cerebral  and  Spinal  Localizations  by  M. 
Allen  Starr;  on  Cranial  Temperatures  and  on  Neurasthenia  by  L. 
C.  Gray;  on  Degenerative  Neuritis,  by  W.  H.  Leszynsky;  on  Po- 
liomyelitis, by  Wharton  Sinkler;  on  Craniometry  and  Cranial  De- 
formities, by  V.  Peterson  and  by  E.  D.  Fisher;  on  Angioneurotic 
(Edema,  by  Jos.  Collins;  on  Brain  Tumors,  by  P.  C.  Knapp,  and 
on  Sclerosis  of  the  Cord,  by  J.  J.  Putnam.  I  am  indebted  to 
Tourette's  recent  treatise  on  hysteria,  to  that  of  Fere  on  epilepsy, 
and  to  the  annual  volumes  of  Bourneville  on  these  subjects.  The 
masterly  lectures  of  Charcot  and  the  treatises  of  Ross,  Gowers, 
Hammond,  Hamilton,  and  Putzel  have  necessarily  been  freely  used. 
In  the  anatomical  part  1  have  used  the  works  of  Edinger,  to 
whose  courtesy  I  am  particularly  indebted,  the  treatise  of  Ober- 
steiner,  and  many  monographs  by  Golgi,  Marchi,  Cajal,  His,  Wal- 
deyer,  and  others.  My  own  work  in  teaching  anatomy  and  pathol- 
ogy has  enabled  me  to  do  more  than  present  a  compilation. 

I  must  finally  express  my  thanks  to  my  publisher,  Mr.  W.  H. 
S.  Wood,  for  his  patience  and  helpful  generosity  in  my  efforts  to 
make  my  work  a  production  that  would  be  creditable  to  American 
neurology. 

To  the  Student. 

As  a  special  text-book  the  present  work  will  be  used  by  two 
classes  of  readers,  one  consisting  of  those  who  simply  consult  it  for 
reference  in  connection  with  their  cases,  the  other  composed  of  stu- 
dents who  desire  to  ground  themselves  systematically  in  a  knowl- 
edge of  neurology.  To  this  latter  class  I  venture  some  advice  as 
to  the  method  they  should  pursue.  Neurology  is  a  difficult  branch 
of  medicine  to  master,  nor  is  there  any  royal  road  to  it.  Still,  it 
can  be  made  comparatively  easy  if  its  study  is  undertaken  in  a 
proper  and  systematic  way. 

In  using  the  present  work,  the  student  should  first  refresh  li is 


PREFACE.  V 

general  knowledge  of  nervous  anatomy  as  furnished  in  ordinary 
text-books.  He  should  then  go  carefully  over  the  anatomical  de- 
scriptions here  given  of  the  general  structure  of  the  nervous  system 
and  of  that  of  the  nerves,  spinal  cord,  and  brain.  A  thorough 
knowledge  of  anatomy  and  physiology  makes  clinical  neurology 
comparatively  easy,  and  in  fact  reduces  much  of  it  simply  to  a  mat- 
ter of  logical  deduction. 

The  student  should  next  master  the  general  facts  of  nervous 
pathology,  symptomatology,  and  etiology,  for  he  will  find  common 
laws  underlying  apparently  the  most  varying  phenomena.  Finally. 
he  must  begin  to  study  the  special  diseases.  The  number  of  these 
is  very  great;  in  the  present  work  I  have  described  176.  Many  of 
these  are  rare,  and  it  would  be  wrong  for  the  student  to  burden  his 
memory  with  the  details  about  them.  He  need  know  only  of  their 
existence  and  general  physiognomy.  There  are,  however,  accord- 
ing to  my  enumeration,  about  65  nervous  diseases  which  are  either 
very  common  or  extremely  important,  and  it  is  these  that  the  stu- 
dent should  master  and  make  part  of  his  working  knowledge. 
Since  the  distribution  and  names  of  the  common  and  rare  diseases 
may  be  a  useful  guide,  I  append  here  a  table  and  a  list : 


Peripheral. 

Spinal  Cord. 

Brain. 

Functional. 

Totals. 

Common   and   important 

nervous  diseases 

Rare 

31 
56 

13 

27 

12 
16 

10 
11 

65 

111 

87 

40 

28 

21 

176 

The  common  or  important  nervous  diseases  are  : 

General.  —  Neuritis,  multiple  neuritis,  degeneration,  neuralgia, 
paresthesia  (5). 

Cranial  Nerves. — Anosmia,  optic  neuritis,  optic  atrophy,  ptosis, 
ophthalmoplegia,  abducens  palsy,  headache,  migraine,  trigeminal 
neuralgia,  facial  spasm,  facial  palsy,  tinnitus,  vertigo,  ageusia, 
wryneck  (16). 

Spinal  liferves. — Cervical  neuralgia,  hiccough,  brachial  palsies, 
single  and  combined,  brachial  neuralgia,  intercostal  neuralgia, 
herpes  zoster,  lumbar  neuralgia,  sciatica,  leg  palsies  (10). 

Spinal  Cord. — Spina  bifida,  hemorrhage,  pachymeningitis,   lep- 


VI  PREFACE. 

toineningitis,  poliomyelitis,  transverse  myelitis,  acute  and  chronic, 
secondary  degenerations,  locomotor  ataxia,  the  progressive  muscu- 
lar atrophies,  bulbar  palsy,  muscular  dystrophies,  spinal  irritation 
(13). 

Brain. — Malformations,  hyperaemia,  pachymeningitis,  leptomen- 
ingitis, simple,  tuberculous,  and  epidemic,  abscess,  hemorrhage, 
embolism,  thrombosis,  children's  palsies,  syphilis  (12). 

Functional. — Epilepsy,  hysteria,  the  tics,  chorea,  tetanus,  neu- 
rasthenia, spermatorrhoea,  exophthalmic  goitre,  occupation  neuro- 
ses, paralysis  agitans  (10). 


PREFACE   TO   THE   FIFTH   EDITION. 


The  present  edition  of  this  work  contains  some  minor  changes 
in  regard  to  the  microscopical  anatomy  of  the  nervous  system  and  a 
short  chapter,  with  illustrations,  upon  the  diagnosis  of  diseases  of 
the  cauda  equina.  I  have  rewritten  the  chapter  upon  myelitis,  and 
have  added  a  chapter  on  general  paresis,  since  that  is  a  disorder 
which  belongs  fully  as  much  to  neurology  as  to  psychiatry.  Fi- 
nally, a  number  of  new  cuts  have  been  added,  some  of  the  old  ones 
have  been  replaced,  and  a  number  of  minor  corrections  hi  the  general 
text  have  been  made.  The  elisions  have  been  sufficient  to  enable  me 
to  make  these  various  additions  without  enlarging  the  size  of  the 
book.  I  am  much  indebted  to  my  friend,  Dr.  George  L.  Walton, 
for  valuable  criticisms  and  suggestions. 

New  York,  September  27th,  1901. 


PEEFACE  TO  THE  FOURTH  EDITION. 


Five  years  have  passed  since  the  first  edition  of  this  work,  and 
I  find  it  requires  a  good  many  changes  in  order  to  meet  the  de- 
mands of  neurology  as  it  is  to-day.  I  have  therefore  given  the 
book  a  very  complete  revision  and  have  entirely  rewritten  many 
parts  of  it.  The  chapters  on  the  Microscopic  Anatomy  of  the  Ner- 
vous System  and  on  the  Anatomy  of  the  Spinal  Cord  and  Brain  are 
practically  new,  and  have  been  made  to  conform  more  completely 
with  present  views  regarding  the  importance  of  the  neuron.  The 
chapters  on  the  Peripheral  Nervous  System  have  been  rewritten 
and  rearranged.  The  articles  on  Acute  Encephalitis,  Multiple 
Sclerosis,  and  Combined  Sclerosis  are  also  practically  new,  as  is 
also  the  chapter  on  Neurasthenia.  I  have  added  a  chapter  on  Al- 
coholic Meningitis.  The  practical  side  of  our  art  has  been  borne  in 
mind;  such  additions  have  been  made  to  therapeutics  as  my  expe- 
rience justified  me  in  recommending.  Many  of  the  old  cuts  have 
been  removed  and  a  large  number  of  new  ones  substituted.  With 
all  this,  however,  I  have  not  materially  added  to  the  bulk  of  the 
volume.  It  has  been  my  purpose  from  the  beginning  to  have  my 
work  fill  the  space  that  should  be  occupied  by  a  compendium  rather 
than  that  of  an  encyclopaedia. 

The  number  of  nervous  diseases  has  not  lessened  as  the  years 
have  rolled  by,  but  their  grouping  and  relations  are  better  under- 
stood and  the  essential  unity  of  many  groups  has  been  made  more 
distinct.  I  must  still  give  practically  the  advice  to  the  medical 
student  which  is  found  in  the  preface  to  my  first  edition.  Those 
who  read  the  present  volume  will,  perhaps,  be  somewhat  disturbed 
at  first  by  the  new  nomenclature  which  has  so  much  to  say  about 
neurons,  dendrites,  and  neuraxons.  These  things,  however,  have 
come  to  stay  with  us  anatomically,  and  the  modern  student  must 
become  familiar  with  them.  I  have  to  confess,  however,  that  our 
conception  of  the  neuron  has  aided  us  more  in  our  anatomical  work 


PREFACE   TO    THE    FOURTH    EDITION.  IX 

than  in  our  pathology.     The  practical  application  of  the  neuron 
to  disease  has  not  yet  furnished  us  very  much  help. 

I  must  express  my  appreciation  of  the  liberal  way  in  which  my 
publishers  have  co-operated  in  the  difficult  task  of  reconstructing 
this  work.  I  cannot,  also,  help  expressing  the  indebtedness  which 
I  am  under  to  numerous  masters  of  neuro-pathology  and  anatomy, 
whom  one  must  consult  and  from  whom  one  must  learn  so  much  of 
what  he  has  to  present  in  a  systematic  treatise  like  this. 
New  York,  Sept.  22d,  1897. 


TABLE  OF' CONTENTS. 


CHAPTER  I. 

PAGE 

General  Anatomy,  Physiology,  and  Chemistry.  General  Histol- 
ogy— Neuronic  Architecture  of  the  Nervous  System,         ...         1 

CHAPTER  II. 
The  Causes  of  Nervous  Diseases 23 

.      CHAPTER  III. 

General  Pathology, 27 

CHAPTER  IV 

General  Symptoms, ....      31 

CHAPTER  V. 

Diagnosis    and    Methods    of     Examination.      Degeneration — Skull 

Measurements — Disorders  of  Motility,  of  Sensation,  ...      39 

CHAPTER  VI. 

Hygiene,  Prophylaxis,  Treatment.     Diet — Exercise— Hydrotherapy 

— Massage — Climate— Electro-Therapy 60 

CHAPTER   VII. 

General  Diseases  of  the  Peripheral  Nerves.  Anatomy — Pathol- 
ogy—Symptoms—Multiple Neuritis— Tumors,  ....      78 

CHAPTER  VIII. 

Motor  Neuroses  op  Cranial  Nerves,  Cranial  Nerves— The  Ocular 
Nerves—  Anatomy  —  Symptoms  —  The  <  >phtbalmoplegias  —  The 
Spasms — The  Fifth  Nerve— The  Facial  Nerve— The  Glosso-Pharyn- 
gealNervt — The  Vagus— The  Spinal  Accessory— The  Hypoglossus,      98 

CHAPTER  IX 

Motor  Neuroses  of  the  Spinal  Nerves  The  Upper  Cervical — The 
Lower  Cervical  and  Brachial — The  Thoracic— Thfi  Lumbar — The 
8acral 131 


Xll  CONTEXTS. 


CHAPTER  X. 

PAGE 

Sensory  Neuroses  or  TnE  Cerebro-Spinal  Nerves.  Paresthesia — 
Neuralgia — Neuroses  of  the  Nerves  of  Special  Sense— Headache — 
Tinnitus — Vertigo — Neuroses  of  the  Sensory  Spinal  Nerves — Vaso- 
motor and  Trophic  Neuroses, 152 

CHAPTER  XL 

Diseases  of  the  Spinal  Cord.     Anatomy  and  Physiology,         .        .     208 

CHAPTER  XII. 

Diseases  op  the  Spinal  Cord.     Malformations — Spinal  Hemorrhage 

— The  Caisson  Disease — Hyperemia — Anaemia — Meningitis,     .         .     234 

CHAPTER  XIII. 
Myelitis, 249 

CHAPTER  XIV. 

Degenerative  Diseases.     Locomotor  Ataxia — Spastic  Spinal  Paralysis 

— Combined  Scleroses, 270 

CHAPTER  XV. 

Progressive  Muscular  Atrophies,  Muscular  Dystrophies.  Amyo- 
trophic Lateral  Sclerosis — Asthenic  Paralysis,       -  .         .         .         -     308 

CHAPTER  XVI. 

Tumors   and   Cavities   of   the   Spinal   Cord.     The  Recognition  of 

Diseases  of  the  Cauda  Equina 330 

CHAPTER  XVII. 
Anatomy  and  Physiology  of  the  Brain, •    343 

CHAPTER   XVIII. 

Diseases  of  the  Brain.  General  Symptoms— Irritation — Compression 
— Hemiplegia — Aphasia  —  Malformations —  Anaemia — Hyperemia — 
Meningitis, •'        •     385 

CHAPTER  XIX. 

Diseases    of    the    Brain.      Inflammations — Multiple    Sclerosis — The 

Apoplexies —Infantile  Cerebral  Palsies, 405 

CHAPTER  XX 
Tumors  of  the  Brain.     Syphilis, 445 


CONTENTS.  Xlll 

CHAPTER  XXI. 

PAGE 

General  Paresis.     General  Paralysis  of  the  Insane — Dementia  Paraly- 
tica,  467 

CHAPTER  XXII. 
Functional  Nervous  Diseases.     Epilepsy, 474 

CHAPTER  XXIII. 
Hysteria.     The  Tics — Myoclonus — Thomsen's  Disease,  .        .        .     487 

CHAPTER  XXIV. 
The  Acquired  Neuroses.     Chorea  —Tetany, 507 

CHAPTER  XXV. 

Neurasthenia.     Sexual    Neuroses — Traumatic    Neuroses — Exophthal- 
mic Goitre, 519 

CHAPTER  XXVI 
The  Occupation  Neuroses, T>1 

CHAPTER  XXVII. 
Paralysis  Agitans, 561 

CHAPTER  XXVIII. 

Tbophii     \.m)  Vasomotor   Disorders.     Hemiatrophy — Acromegaly— 

Myxoedema — Cretinism — Angioneurotic  (Edema,     ....     568 

CHAPTER  XXIX. 

The    Disorders    of   Sleep.     Insomnia — Hypnotism — Morbid    Somno- 
lence— Catalepsy— Trance — Lethargy — The  Sleeping  Sickness.  577 

CHAPTER  XXX. 
Ckamo-Cerebrai.  Topograph? 592 

APPENDIX. 
Neurological  Therapeutics, :>!'^ 


DISEASES  OF  THE  NERVOUS  SYSTEM. 


PART  I. 


CHAPTER   I. 

GENERAL    ANATOMY,  PHYSIOLOGY,  AND    CHEMISTRY. 

In  studying  the  phenomena  of  life  in  the  human  body,  we  as 
physicians  first  learn  about  its  normal  structure  and  functions.  We 
then  note  the  new  phenomena  which  develop  when  disease  comes 
on,  the  causes  which  produce  them,  and  the  anatomical  changes 
lying  back  of  them;  we  group  our  facts  and  give  the  disease  a  name. 
Lastly  we  apply  the  methods  by  which  the  disorder  can  be  expelled 
and  future  attacks  prevented.  In  fine,  we  investigate  our  subject 
just  as  we  do  that  of  any  branch  of  natural  history.  Our  study 
divides  itself,  therefore,  into 

Normal  anatomy  and  physiology. 

Etiology,  a  study  of  the  causes. 

Symptomatology,  a  study  of  the  morbid  phenomena. 

Pathology,  under  which  we  include  a  study  of  the  morbid  anat- 
omy and  physiology. 

Diagnosis,  or  the  method  of  recognizing  and  separating  out  the 
different  groups  of  diseases. 

Prognosis,  a  foreeast  of  the  future  course  of  the  malady. 

Treatment  and  prophylaxis. 

Again,  although  nervous  diseases  show  many  phases  and  have 
many  different  morbid  changes  behind  them,  there  are  certain  fea- 
tures common  to  all.  It  simplifies  their  study,  therefore,  to  learn 
first  what  these  general  features  are,  just  as  a  person  can  better  sur- 
vey and  plot  out  country  in  detail  if  he  knows  certain  general  facts 
about  its  boundaries  and  topography.  Hence  I  shall  first  present 
in  a  general  way  an  outline  of  the  fundamental  facts  that  touch 
more  or  less  on  all  forms  of  nervous  disease.  My  first  chapters  will 
1 


2 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


be  devoted  to  a  general  description  of  the  anatomy  and  physiology, 
and  then  of  the  etiology,  symptomatology,  pathology,  diagnosis, 
prognosis,  and  treatment. 


GENERAL  ANATOMY. 

The  nervous  system  is  derived  from  the  epiblastic  layer  of  the 
developing  ovum,  and  its  constituents  are  modifications  of  epithelial 
cells.  These  cells  in  the  embryo  are  of  two  kinds : 
neuroblasts,  which  develop  into  nerve  cells  and  fibres ; 
and  spongioblasts,  which  develop  into  a  supporting 
structure  called  neuroglia  (His). 

The  nervous  system  is  composed  of: 

(a)  Neurons,  which  form  the  nervous  tissue 
proper,  and  are  made  up  of  nerve  cells,  of  their 
processes,  one  of  which  becomes  a  nerve  fibre;  and 
neuroglia. 

(b)  Non-nervous  tissue,  consisting  of  connective 
tissue,   blood-vessels,  lymphatics,  and  epithelium. 

These  tissues  are  united  together  to  form  a  cen- 
tral nervous  system,  consisting  of  the  brain,  spinal 
cord,  and  the  peripheral  nervous  system.  This 
latter  is  composed  of  nerve  fibres,  and  structures 
attached  to  the  terminations  of  the  nerves,  called 
and  finally   the   ganglionic    or    sympathetic    nervous 


Fig.  1. 


end-organs, 
system. 

The  Arrangement  of  the  Nervous  System. — The  subdivisions 
of  these  parts,  and  their  descriptions  in  detail,  belong  to  gen- 
eral anatomy.  But  there  have  been  so  many  special  subdivisions, 
and  particular  names  given  to  them  in  recent  years,  that  I  deem  it 


Fig.  -Z. 


necessary,  in  order  to  prevent  confusion,  to  describe  briefly  the 
subdivisions  accepted  by  modern  anatomists.     The  names  here  used 


GENERAL   ANATOMY,   PHYSIOLOGY,  AND    CHEMISTRY.  3 

are  those  adopted  by  the  committee  on  anatomical  nomenclature  of 
the  German  Anatomical  Society,  and  they  have  also  been  adopted 
by  a  large  number  of  writers  on  neuro-anatomy . 

Beginning  with  the  brain,  we  find  that  its  particular  subdivisions 
are  based  upon  the  embryological  development  of  this  organ.  As 
will  be  shown  in  more  detail  later,  the  brain  is  developed  out  of 
three  vesicles,  known  as  the  anterior,  middle,  and  posterior  vesicles 
(Fig.  1).  The  most  anterior  of  these  vesicles  is  the prosencephalon 
or  anterior  brain  ;  the  middle  vesicle  becomes  the  mesencephalon  or 
mid-brain,  and  the  posterior  vesicle  develops  into  the  rhombencepha- 
lon ox  posterior  brain. 

'Prosencephalon  \  1.   Telencephalon, 

(anterior  brain).         (2.   Diencephalon. 


Brain. 


I1  and  P 

Mesencephalon  \  3.  Mesencephalon 

(middle  brain). II 

Rhombencephalon         (f  ^^halon, 


III  and  IV 

The  anterior  vesicle  develops  two  secondary  vesicles :  the  an- 
terior portion  of  these,  including  the  corpora  striata,  olfactory  lobes, 
and  the  cerebral  hemispheres,  forms  the  telencephalon,!2  while 
the  hinder  portion  of  this  vesicle,  which  includes  the  thalamus  and 
mammary  bodies,  forms  the  diencephalon  (I1).  The  middle  vesicle  is 
the  mesencephalon,  and  it  includes  the  corpora  quadrigemina  and 
cerebral  peduncles  (II).  The  posterior  vesicle  is  divided,  from  before 
backward,  into  three  different  parts:  (1)  the  isthmus,  which  in- 
cludes the  superior  cerebellar  peduncles  and  valve  of  Vieussens,  and 
part  of  the  cerebral  peduncles;  (2)  the  metencephalon  or  hind-brain, 
which  includes  the  cerebrum  and  pons  Varolii;  and  (3)  the  myelen. 
cephalon  or  after-brain,  which  includes  the  medulla  oblongata. 

These  different  parts  can  be  understood  better  by  means  of  the 
accompanying  figure  (Fig.  2),  which  represents  in  a  schematic  way 
the  brain  of  a  mammal  (Edinger). 

They  are  intimately  connected  by  strands  of  nerve  fibres,  and 
are  connected  closely  also  with  the  next  portion  of  the  nervous 
system,  the  spinal  cord.  The  brain  and  spinal  cord  are  spoken 
of  as  a  cerebro-spinal  axis,  and  this  is  in  close  relation  with  the 
peripheral  nervo\is  system. 

This  peripheral  nervous  system  is  composed  of  two  portions — 
first,  the  cerebro-spinal  mixed  nerves,  whose  origin,  distribution, 
and  relations  are  comparatively  easy  to  follow;  and  Becond,  the  gan- 
glionic or  sympathetic  nervous  system.  This  has  relations  which 
are  not  so  easily  described,  and  which  are  as  yet  not  wholly  under- 


DISEASES    OF    THE   NERVOUS   SYSTEM. 


stood.  This  portion  of  the  nervous  system  is  composed  of  two  sets 
of  ganglia  —  one  the  vertebral  ganglia,  i.e.,  the  chain  of  gan- 
glionic masses  on  each  side  of  the  vertebral  column,  and  of  cer- 
tain ganglia  connected  with  the  cranial  nerves;  secondly,  a  very 
large  number  of  ganglionic  masses  distributed  in  the  viscera,  and 
known  as  the  peripheral  ganglia.     The  sympathetic  nervous  system 


Fig.  3. 


-Multipolar  Cell  of  First  Type.     Cell  of  Deiter. 
neuraxon  (Van  Gehuchten). 


The  continuous  line  is  the 


is  made  up  very  largely  of  nerves  from  the  cerebro-spinal  centres. 
Motor  fibres  pass  out  through  the  anterior  roots  of  the  spinal  cord, 
sensory  fibres  arise  from  the  posterior  spinal  ganglia,  and  both  pass 
in  part  to  the  peripheral  ganglia  and  the  viscera  direct,  and  part  to 
cells  in  the  vertebral  ganglia,  with  which  they  are  connected.  The 
ganglionic  system  contains  also  nerve  cells  of  its  own,  which  are, 
however,  in  dependence  in  the  main  upon  influences  from  the  cere- 
bro-spinal centres.     Some  of  these  cells  send  fibres  into  the  spinal 


GENERAL    ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY.  5 

cord,  and  according  to  Collins  and  Onuf  the  sympathetic  ganglia 
have  representations  in  the  spinal  gray  matter. 

The  General  Histology  of  the  Xervous  System. 

The  nerve  cells  form  the  central  body  of  the  neuron  and  are 
minute  objects  varying  much  in  size.  The  largest  are  .1  mm.  (j^-  in.) 
in  diameter  and  are  almost  visible  to  the  naked  eye.  The  smallest 
are  .7//  (3-=Vir  incn)  iQ  diameter;  so  that  the  average  diameter  is 
rather  greater  than  that  of  a  white  blood  cell.     In  shape  nerve  cells 


Fig.  4.— Multipolar  Cell  op  Second  Type.    Cell  of  Golgi.    The  neuraxon  la  gl^en  off  at 
the  base,  soon  dividing  and  subdividing  (Van  Gehuchten). 

are  for  the  most  part  irregularly  spheroidal,  but  some  are  pyramidal, 
others  spindle  or  flask  shaped,  and  others  globular.  They  all  give 
off  one  or  more  fine  processes  or  poles,  and  hence,  in  accordance  with 
the  number  of  these,  the  nerve  cells  are  often  spoken  of  as  multi- 
polar, bipolar,  or  unipolar. 

In  most  cells  one  of  the  processes  is  continued  on  a  long  way  and 
finally  becomes  a  nerve  fibre.      This  process  is  called  the  axis  cylin- 


6 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


der,  or  neuraxon  *  (Figs.  3  and  4  and  plate).  The  other  processes 
are  relatively  short  and  are  called  protoplasmic  processes,  or  den- 
drites. The  nerve  cell,  then,  is  a  protoplasmic  body  giving  off  ssv- 
eral  dendrites  and  usually  a  single  neuraxon,  the  whole  forming  the 
neuron.  The  dendrites  branch  off  irregularly  and  subdivide,  but 
never  anastomose.  In  some  parts  of  the  nervous  system  they  have 
upon  them  little  nodules  or  buds,  and  in  the  cerebral  and  cerebellar 
cortex  these  are  so  numerous  as  to  give  them  the  appearance  of  bud- 
ded stalks.  The  dendrites  are  usually  not  very  long,  but  in  some 
cells  they  extend  a  very  great  way,  reaching  many  times  the  diam- 


\*r*  *y*&**»- 


-•V 

BIN   4si 


^«.4*w4»*- '  *******   j,*******"" "  ^JP*' 


Fig.  5.— Nerve  Cell  of  Posterior  Spinal  Ganglion  of  a  Frog  (greatly  magnified), 
showing  nucleus,  nucleolus;  just  to  the  left  of  these  is  the  centrosome.  The  dark  masses 
are  the  chromophilic  granules  (Lenhossek). 


eter  of  the  cell.  The  axis-cylinder  process,  or  neuraxon,  is  given 
off  directly  from  the  body  of  the  cell,  as  a  rule.  It  very  soon  be- 
comes clothed  with  a  thin  sheath  (myelin  sheath),  and  as  it  passes 
along  gives  off  branches  at  right  angles,  which  form  what  are  known 
as  the  collaterals.  The  neuraxon  and  collaterals  finally  end  by 
splitting  up  into  a  number  of  fine  branches,  which  lose  their  myelin 
sheath  and  form  the  end  brush  or  terminal  arborization.  The  axis- 
cylinder  process  or  neuraxon  does  not  anastomose  with  other  cells 
either  through  its  own  end  brush  or  through  the  end  brushes  of 
its  collaterals.  The  end  brushes,  however,  pass  in  among  the  den- 
*  The  name  axon  is  also  given  to  it. 


GENERAL   ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY. 


=C*a 


drites  of  other  cells,  and  sometimes  closely  surround  the  cell  body. 
In  this  way  one  neuron  comes  into  very  intimate  relation  with 
others,  but  there  is  never  any  true  union.  Each  neuron  of  the  ner- 
vous system  is  an  independent  unit.* 

There  still  remain  some  important  facts  to  be  stated  regarding 
the  intimate  structure  of  the  cell  body  proper.  This  is  composed  of 
a  semifluid  albuminous  sub- 
stance, somewhat  like  the 
white  of  an  egg,  and  spoken 
of  in  a  general  way  as  pro- 
toplasm, or,  more  specifi- 
cally, as  the  cytoplasm,. 
Within  this  lies  the  nucleus 
and  within  the  nucleus  a 
nucleolus.  The  body  prop- 
er is  not  homogeneous, 
but  is  made  up  of  a  net- 
work of  fine  fibres  or  fibril- 
lar which  pass  in  bundles 
from  dendrite  to  dendrite 
and  from  dendrite  to  the 
neuraxon.  This  fine  fibril- 
lary network  is  not  stain- 
able  by  ordinary  dyes  and  is 
called  the  achromatic  sub- 
stance of  the  cell.  With- 
in its  meshes  and  arranged 
in  a  rather  definite  manner 

are  certain  stainable  bodies  called  Nissl  or  chromophilic  granules. 
These  form  the  chromatic  substance  of  the  cell.  While  most  nerve 
cells  have  these  granules,  some,  such  as  the  granule  cells  of  the 
cerebellum,  do  not.  The  nerve  cells  which  do  stain  and  have  the 
chromophilic  granules  are  called  somatochromes,  the  others  are 
called  karyocnromes  (Nissl).  The  chromophilic  granules  are  ar- 
ranged differently  in  cells  of  different  function.  They  are  believed 
to  represent  the  nutrient  substance  of  the  cell,  while  the  fibrillae 
form  the  conducting  and  functioning  part  (Fig.  5  and  plate).  The 
cell  body  usually  contains  a  little  pigment  (Fig.  6). 

The  nucleus  of  the  cell  is  a  small  spherical  body,  which  is  also 

*  This  view  is  now  denied  by  certain  authorities,  and  there  is  no  doubt 
that  in  some  of  the  lower  animals  fibrils  from  the  end-brushes  of  one  neuron 
pass  into  the  dendrites  of  another  and  thence  through  the  body  of  the  cell  into 
its  neuraxon.  But  though  there  may  be  this  anatomical  unity,  the  genetic 
and  physiological  independence  of  the  neurons  still  continues  to  be  a  fact. 


Fig.  6.— Multipolar  Cell.    Pigment  is  seen  at  d. 


8  DISEASES   OF   THE    NERVOUS   SYSTEM. 

made  up  of  a  reticulated  structure  known  as  the  chromatin  network, 
because  of  its  taking  up  dyes  and  staining  very  intensely.  Besides 
this  network,  however,  there  is  a  finer  network,  which  is  similar  to 
that  in  the  body  of  the  cell,  and  which  is  known  as  the  limn  net- 
work. The  chromatin  is  practically  identical  with  nuclein.  Within 
the  nucleus  is  a  smaller  body,  known  as  the  nucleolus,  which  stains 
still  more  intensely. 

[Nerve  cells  are  surrounded  by  a  pericellular  space,  but  are  not 
inclosed  in  capsules,  excepting  those  of  the  posterior  spinal  and  ver- 
tebral ganglia. 

Central  Nerve  Cells. — There  are  three  kinds  of  central  nerve 
cells,  that  is,  cells  lying  in  the  brain  and  cord,  and  they  are  classi- 
fied in  accordance  with  the  peculiarities  of  the  axis  cylinders  (neu- 
raxons)  into : 

1.  Cells  of  the  first  type,  or  cells  of  Deiter.  These  are  the  kind 
just  described  above,  and  they  form  the  great  mass  of  nerve  cells. 
The  neuraxon  is  continued  as  a  nerve  fibre  (Fig.  3). 

2.  Cells  of  the  second  type,  or  cells  of  Golgi.  In  these  the 
axis  cylinder  soon  gives  off  numerous  collaterals  and  quickly  splits 
into  a  number  of  fine  branches.  None  of  these  branches  ends  in 
becoming  a  nerve  fibre  and  none  travels  far  from  the  cell  body 
(Fig.  4). 

3.  Cells  of  the  third  type,  cells  of  Cajal.  In  these  there  are 
two  or  more  neuraxons.  They  are  found  in  the  superficial  layer  of 
the  cerebral  cortex. 

Peripheral  Nerve  Cells. — The  cells  of  the  peripheral  nervous 
system  resemble  fundamentally  the  central  nerve  cells,  but  undergo 
some  changes  in  order  to  adapt  themselves  to  their  peculiar  func- 
tions. Thus  the  cells  of  the  posterior  spinal  ganglia  have  quite 
peculiar  anatomical  characters.  They  are  rather  large  in  size,  being 
from  29  to  60//  (T-J-jj  to  -^  inch).  They  are  spheroidal  in  shape  and 
have  one  process,  which  speedily  divides  in  two,  in  a  T-shaped 
fashion.  They  are  surrounded  by  an  endothelial  sheath,  which  is 
analogous  to  the  myelin  sheath  of  the  nerve  fibre.  The  cells  have 
one  large  nucleus  with  a  nucleolus.  The  body  is  composed  of  short 
granular  fibres,  which  are  arranged  in  a  somewhat  concentric  layer.  * 

*In  the  centre  of  this,  in  invertebrates  and  the  lower  vertebrates  at  least,  is 
a  body  which  is  called  a  centrosome.  This  is  a  minute  object  which,  as  a  rule, 
lies  outside  though  near  the  nucleus,  and  is  surrounded  by  a  radiating  area  of 
granules,  known  as  the  centrosphere  or  attraction  sphere.  It  may,  however, 
lie  within  the  nucleus.  The  centrosome  is  believed  to  be  the  especial  organ 
of  cell  division,  and  the  dynamic  centre  of  the  cell  (Fig.  5).  The  spinal 
ganglionic  cell  in  the  mammal  is  unipolar;  in  the  lower  vertebrates  it  is 
bipolar.  It  has  been  shown  that  these  two  poles  have  in  higher  vertebrates 
simply  become  fused  into  one. 


GENERAL   ANATOMY,  PHYSIOLOGY,  AND    CHEMISTRY. 


9 


The  nerve  cells  of  the  sympathetic  or  vertebral  ganglia  are  very 
like  the  central  nerve  cells  in  the  anterior  horns.  They  are  multi- 
polar in  shape  and  have  dendrites  and  a  neuraxon.  The  neuraxon 
goes  to  other  neighboring  cells,  or  it  passes  on  and  becomes  a  fibre 
of  Reinak.  The  cell  is  surrounded  by  a  connective-tissue  capsule 
lined  with  endothelium,  like  those  of  the  posterior  spinal  ganglia. 
The  peripheral  or  terminal  sympathetic  nerve  cells  lying  in  the 
viscera  resemble  those  of  the  vertebral  ganglia.  The  cells  of  the 
special  sense  organs  have  many  peculiarities  of  shape  and  structure, 


Fig.  7. — From  a  Transverse  Section  through  the  Sciatic  Ner  je.  ep,  Epineurium  . 
p,  perineurium;  n.  nerve  fibres  constituting  a  nerve  bundle  or  fasciculus  in  cross-sectiou , 
/,  fat  tissue  surrounding  the  nerve  (Klein). 


but  they  are  all  developments  of  the  same  model.  In  the  retina 
and  olfactory  bulb  there  are  cells  without  axis  cylinders  (spongio- 
blasts of  Cajal  and  granules  of  olfactory  bulb). 

.  Nerve  cells  are  classified  in  accordance  with  their  shape  and 
number  of  processes.  The  multipolar  cell  is  the  common  type  and 
is  found  throughout  the  brain,  cord,  and  sympathetic  ganglia.  Bi- 
polar cells  are  found  chiefly  in  the  column  of  Clark  of  the  spinal 
cord;  and  unipolar  cells  in  the  posterior  spinal  ganglia.  .Small 
nuclear  cells  and  flask-shaped  or  Purkinje's  cells  are  found  in  the 
cerebellum.  Besides  these  there  are  described  in  the  brain  cortex 
angular,  granular,  pyramidal,  globose,  and  spindle  cells. 

The  nerve  fiuuks  of  the  nerve  centres  are  found  chiefly  iu  the 
white  tissue  or  white  matter.  In  the  periphery  they  form  the  nerve 
proper  of  gross  anatomy.  The  peripheral  nerve  is  composed  of 
bundles  of  nerve  fibres  called  nerve  fasciculi  (Fig.  7).  It  is  sur- 
rounded by  a  connective-tissue  sheath  called  the  sheath  of  Henle, 
or  epineurium.     From  this  sheath,  connective-tissue  fibres  pass  in 


10 


DISEASES   OF   THE   NERVOUS    SYSTEM. 


and  surround  the  fasciculi.  The  sheath  of  the  fasciculus  is  called 
the  perineurium.  From  the  perineurium,  strands  of  connective 
tissue  run  in  among  the  ultimate  nerve  fibres,  forming  the  endo- 


Fig.  8.  —Diagram  showing  the  Different  Parts  of  the  Nerve.  From  without  in- 
ward we  have:  1,  Nerve  with  epineurium;  2,  nerve  fasciculus,  with  perineurium;  3,  nerve 
fibre  and  endoneurium ;  1,  neurilemma,  myelin  sheath,  axis  cylinder,  primitive  fibrillse. 

neurium  (Fig.  8).     Lymphatic  spaces  lined  with  endothelium  exist 
m  the  layers  of  the  peri-  and  endo-sheaths.     In  the  nerve  centres, 


ml/ 


Fig.  10. 


Fig.  11. 


Fig.  9.  — Medullated  Nerve  Fibre,  a,  Axis  cylinder;  n,  nucleus;  m,  medullary 
sheath;  c,  node  of  Ranvier. 

Fig.  10.— Medullated  Nerve  Fibre,  showing  axis  cylinder,  nuclei  of  medullary  sheath 
nodes,  and  oblique  incisures  of  Schmidt. 

Fig.  11.  — Medullated  Nerve  Fibre,  showing  mode  of  division. 


the  nerve  fibres  have  no  such  sheaths,  but  are  supported  by  a  con- 
nective-tissue and  neuroglia  framework. 

The  nerve  fibre  is  a  long  fine  strand  of  tissue  varying  in  diameter. 


GENERAL   ANATOMY,    I'F.YSIOLOGY,    AND    CHEMISTRY.  11 

It  may  be  white  or  gray,  according  to  its  structure.  It  is  composed 
from  within  out  of  (1)  an  axis  cylinder,  (2)  a  myelin  sheath,  and 
(3)  a  neurilemma.  (1)  The  axis  cylinder  is  the  essential  part  of 
the  nerve.  It  is  the  prolongation  of  the  neuraxon  of  a  nerve  cell 
and  consists  of  protoplasm.  It  is  itself  made  up  of  fine  fibrillae 
(primitive  fibrillae)  which  run  longitudinally.  By  means  of  re- 
agents, a  transverse  striation  can  be  seen  also.  (2)  The  myelin 
sheath,  medullary  sheath,  or  sheath  of  Schwann,  surrounds  the  axis 
cylinder.  It  is  composed  of  a  semifluid,  fatty  substance,  which 
chemically  consists  of  lecithin,  neurin,  and  some  cholesterin.  It 
varies  much  in  thickness,  and  this  is  the  principal  cause  of  the 
different  sizes  of  nerves.  The  myelin  sheath  is  interrupted  at  reg- 
ular intervals  by  constrictions  called  the  "  nodes  of  Ranvier. "  These 
constrictions  involve  the  myelin  sheath  alone.  The  axis  cylinder 
passes  through  and  the  outer  sheath  (neurilemma)  passes  over  it. 
There  is  a  little  granular  matter  at  the  point,  called  intercellular 
cement.  The  nerve  fibres,  if  they  divide,  always  do  so  at  a  node 
(Fig.  11).  The  part  between  two  nodes  is  called  a  nerve  segment.. 
In  each  segment  there  is  an  oval  nucleus  embedded  in  the  myelin 
sheath.     The  nodes  are  about  1  mm.  apart. 

The  myelin  sheath  is  probably  developed,  like  the  axis  cylinder, 
from  the  epiblast,  and  is  closely  related  nutritionally  to  the  axis 
cylinder,  which  it  protects  and  isolates.*  (3)  The  neurilemma  or 
primitive  sheath  is  a  delicate  homogeneous  covering  forming  the 
outermost  sheath  of  the  nerve.  It  is  of  connective-tissue  origin. 
The  sheath  is  absent  in  the  fibres  of  the  central  nervous  system 
and  in  some  fibres  of  the  periphery. 

Variations  in  the  Types  of  Fibres. — In  accordance  with  the  ar- 
rangement of  the  sheaths  of  the  nerve  fibres,  several  kinds  are 
described.  The  principal  types  are  the  medullated  and  non-medul- 
lated. 

Medullated  nerve  fibres  make  up  the  bulk  of  the  white  matter  of 
the  brain  and  cord  and  cerebro-spinal  nerves.  They  consist  of  a 
myelin  sheath  and  axis  cylinder,  and  may  or  may  not  have  a  neu- 
rilemma. Fibres  with  myelin  sheath,  but  without  a  neurilemma, 
make  up  the  white  matter  of  the  central  nervous  system. 

Non- medullated  fibres,  or  fibres  of  Remak,  occur  principally  in 
the  sympathetic  system,  but  they  are  also  found  in  the  cerebro- 

*  Between  it  and  the  axis  cylinder  Mauthner  describes  a  membranous 
sheath  (axis-cylinder  sheath).  Another  sheath  is  said  to  be  between  it  and 
the  neurilemma  (medullary  Bbeath).  By  means  of  certain  reagents,  oblique 
lines  (incisures  of  Schmidt)  or  a  reticular  appearance  may  be  developed  (net- 
work of  Gedvelst) .     These  appearances  are,  perhaps,  artificial. 


12 


DISEASES   OF   THE    XERYOUS    SYSTEM. 


spinal  nerves.  They  are  grayish  and  faintly  striated,  and  consist 
of  axis  cylinders,  with  a  thin,  homogeneous,  nucleated  sheath  lying 
directly  upon  them.  This  sheath,  however,  cannot  often  be  demon- 
strated (Schaefer). 

Naked  axis  cylinders  are  found  in  the  peripheral  terminations 
of  nerves  as  well  as  in  the  brain  and  cord. 

Size The  nerve  fibres  are  of  two  kinds  as  regards  size.     The 


Fig.  12. 


Fig.  13. 


Fig.  12.—  Non-medullated  Nerve  Fibre,    n.  Nucleus;  6,  striations. 

Fig.  13. — Diagram  showing  the  Neuron  and  Mode  of  Connection  between  Nervb 
Units  throughout  the  Nervous  System.  1,  Nerve  cell;  2,  nervous  process;  3,  col- 
lateral; 4,  end  brush;  5,  nerve  cell. 


small  fibres  are  about  2,a  or  j  5  *  6  „  inch  in  diameter,  the  large  20/j 
or  y-jVzr  inch.  The  small  fibres  are  connected  with  smaller  cells, 
and  either  run  a  shorter  course  or  are  distributed  to  the  involuntary 
muscular  fibres  of  the  blood-vessels  and  viscera.  The  motor  fibres 
are  larger  than  the  sensory. 

The  peripheral  nerve  fibres,  except  the  optic,  have  no  neuroglia; 


GENERAL    ANATOMY,    PHYSIOLOGY,    AND    CHEMISTRY. 


13 


they  terminate  in  line  fibrillse  among  epithelial  cells,  or  in  special 
end  organs. 

The  central  riorums  fibres  make  up  the  white  matter  of  the  brain 
and  cord.  They  are,  like  the  peripheral  nerves,  the  prolongations 
of  the  nenraxons.  They  are  composed  of  an  axis-cylinder  process 
and  myelin  sheath,  but  have  no  neurilemma,  and  probably  no  nodes. 
At  frequent  intervals  each  fibre  gives  off  branches  at  right  angles 
forming  the  "collaterals." 

Connections  of  Nerve  Cells  and  Nerve  Fibres. — One  nerve  cell  is 
never  connected  directly  with  another,  so  far  as  anatomical  investi- 
gation can  show.  One  nerve  process  becomes  an  axis  cylinder,  re- 
ceives a  myelin  sheath,  gives  off  collaterals,  and  finally  breaks  up 
into  a  fibrillary  "  end  brush"  surrounding  a  cell,  but  not  passing  into 
it.  There  is  physiological,  but  no  apparent  anatomical  continuity 
(Tig.  13). 

The  Neuroglia. — The  supporting  tissue  of  the  peripheral  nerves 
is  connective  tissue  only ;  that  of  the  central  nervous  system  is  con- 


Fig.  14.— Neuroglia  Cells. 


nective  tissue  and,  in  addition,  a  peculiar  substance  called  neuroglia. 
The  neuroglia  or  supporting  tissue  of  the  nervous  centres  is  derived 
from  the  epiblast.  It  is  composed  of  cells  with  very  numerous  and 
finely  ramified  processes,  which  make  a  supporting  network  about 
the  nerve  cells  and  fibres  (Fig.  14).     The  neuroglia  cells  are  some- 


14 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


times  known  as  "spider  cells."  They  differ  somewhat  in  size  and 
shape,  but  not  in  general  characteristics.  The  cell  body  is  composed 
of  granular  protoplasm,  lying  in  which  is  a  large  nucleus,  within 
which  is  the  nucleolus.  The  body  of  the  cell  is  small  in  amount  in 
proportion  to  the  nucleus.  The  fibrillary  processes  form  a  felt-like 
network,  and  in  regions  where  there  is  much  neuroglia  tissue  this 
looks  like  a  homogeneous  matrix.  It  is,  however,  made  up  of  the 
fine  fibrils.      These  connect  with  the  Avails  of  the  blood-vessels. 


Fig.  15.  Fig.  Hi. 

Fig.  15.— arteries  of  Sciatic  Nerve  (Quenu  and  Lejars). 

Fig.  16.— Arteries  of  the  Median  Nerve.    AA,  Branches  to  the  nerves;  £,  brachial 
artery :  M,  median  nerve  (Quenu  and  Lejars). 

Weigert  has  shown  that  the  processes  become  changed  in  their 
chemical  and  physical  character,  so  that  they  take  a  different  stain 
from  that  of  the  cell  body  itself,  and  thus  form  a  really  separate  struc- 
ture (Plate  I.,  Fig.  7).  In  inflammatory  conditions  the  cells  multi- 
ply, swell  up,  and  assist  in  carrying  off  irritating  products  (scaven- 
ger cells  of  Lewis).  Neuroglia  tissue  is  richly  deposited  about  the 
central  canal  of  the  spinal  cord,  beneath  the  ependyma  of  the  ven- 
tricles, and  beneath  the  pia  mater  of  the  brain  and  cord.     The  epi- 


GENERAL   ANATOMY,   PHYSIOLOGY,  AND    CHEMISTRY. 


15 


thelial  cells  of  the  central  canal  and  ependyma  of  the  ventricles 
send  down  fine  processes  which  form  a  minor  part  of  the  support- 
ing framework. 

The  Nox-xervous  Tissues — The  Blood-vessels. — The  peri- 
pheral nerves  are  richly  supplied 
with  blood.  Each  nerve  receives 
arterial  supply  from  many  differ- 
ent branches,  but  always  from 
the  same  general  source.  The 
artery  passes  to  the  nerve  sheath 
obliquely,  then  divides  dichoto- 
mously  and  sends  branches  a  long 
distance  up  and  down  on  the 
sheath.  It  may  pierce  the  sheath, 
however,  first,  and  then  divide, 
as  above  described.  The  dichoto- 
mous  branches  send  off  arterioles 
and  capillaries,  which  form  plex- 
uses about  the  nerve  fascicles. 
These  are  "the  interfascicular 
arcades."  The  arteries  subdivide 
in  such  a  way  as  to  prevent  sud- 
den impact  of  a  large  blood  stream 
into  the  tissue  of  the  nerve.  In 
this  respect  the  nerve  circulation 
resembles  that  of  the  brain  and 
cord.  The  veins  subdivide  di- 
chotomously,  like  the  arteries. 
They  freely  anastomose  with  the 
muscular  veins,  so  that  muscular 
action  helps  nerve  circulation. 
The  veins  of  the  superficial  nerves 
connect  with  those  of  the  deep 
nerves  (See  Figs.  15,  16,  17). 

The  blood-vessels  of  the  spinal 
cord  and  brain  will  be  described 
later. 

Lymphatic  vessels  and  spaces 
are  found  in  the  epineurium  and 
perineurium.  There  are  no  dis- 
tinct lymphatics  in  the  fas- 
ciculi, but  lymph  spaces  probably 

exist.  Fl°-    l"--JNrERKASCI(Jl-LAlt      DttTHIBOIl 

of  Arteries  (.ycENU  asd  LejarsJ 


16  DISEASES    OF   THE   XEEYOUS    SYSTEM. 


The  ISTetjroxic  Architecture  of  the  Nervous  System. 

Having  described  the  component  parts,  I  shall  now  show  the 
way  in  which  these  parts  are  arranged  to  form  the  nervous  system. 

The  nervous  system,  as  already  shown,  is  composed  of  single 
nerve  units  that  are  called  neurons,  and  the  neuron  is  made  up  of 
a  cell  body  and  numerous  processes,  one  of  which  is  the  neuraxon, 
the  others  the  dendrites. 

The  neuraxon  has  always  the  function  of  carrying  impulses 
away  from  the  cell;  it  is  a  celluf ugal  fibre ;  the  dendrites,  how- 
ever, bring  impulses  to  the  cell,  and  are  cellupetal  in  function.  The 
dendrites  are  in  contact  with  end  brushes  of  the  neuraxons  of  other 
cells,  and  in  this  way  receive  the  nerve  impulse  and  transmit  it  to 
the  cell  body.  The  nervous  system  is  thus  a  mass  of  neurons 
which  are  packed  closely  together,  and  form  with  each  other  most 
intricate  relations,  but  never  connect  directly  one  with  another. 
No  nerve  fibre  or  dendrite  of  one  cell  anastomoses  with  that  of  cm- 
other,  as  blood-vessels  do.  Each  neuron  is  absolutely  anatomically 
independent.   (See  p.  7,  note.) 

It  is  the  purpose  of  this  neuronic  mass  to  receive  impulses  from 
within  or  without  the  body,  to  transfer  and  modify  them,  and  to 
send  out  impulses  in  such  way  as  properly  to  control  the  vital  func- 
tions and  keep  the  individual  in  proper  harmony  with  his  environ- 
ment. The  nervous  system  is  a  great  receiving,  regulating,  con- 
trolling, and  discharging  machine,  the  machinery  being  the  neu- 
rons, the  force  that  works  in  it  being  called  nervous  energy.  The 
nerve  cells  are  the  reservoirs  and  direct  generators  of  this  force, 
while  the  dendrites  and  neuraxons  receive  and  distribute  it.  The 
nerve  cells  are  massed  together  for  the  most  part  in  the  brain  and 
spinal  cord,  forming  the  gray  matter,  while  the  neuraxons  as  dis- 
tributors make  up  the  white  matter  and  the  cranial,  spinal,  and 
sympathetic  nerves.  It  is  convenient  to  make  a  division  therefore 
into  the  central  nervous  system,  or  cerebro-spinal  axis,  and  the 
peripheral  nervous  system,  which  includes  the  cranial  and  spinal 
nerves  and  the  sympathetic  nervous  system.  Since  the  nerve  fibres 
of  the  brain  and  cord  are  white  in  texture,  while  the  cells  in  mass 
are  of  gray  color,  it  is  very  easy  to  distinguish  the  deposits  of  cells 
from  the  fibres  and  thus  make  subdivisions  of  the  central  nervous 
tissue.  One  portion  of  this  gray  matter  is  found  deposited  in  the 
centre  of  the  spinal  cord,  extending  up  to  the  floor  of  the  medulla, 
thence  underneath  and  around  the  aqueduct  of  Sylvius  to  the  floor 
of  the  third  ventricle.     This  is  called  the  central  gray  matter.     An- 


GENERAL    ANATOMY,   PHYSIOLOGY,  AND    CHEMISTRY.  17 

other  deposit,  much  larger  in  amount,  covers  the  whole  of  the  cere- 
brum and  cerebellum,  and  forms  the  cerebral  and  cerebellar  cortex. 
Smaller  deposits  make  up  the  great  basal  ganglia,  corpus  striatum, 
optic  thalamus,  and  corpora  quadrigemina,  besides  several  small  de- 
posits (the  small  basal  ganglia),  such  as  Luys'  body  and  the  red 
nucleus. 

The  peripheral  nervous  system  contains  nerve  cells,  as  well  as 
fibres.  Their  anatomical  arrangement  is  easily  understood,  but  their 
relation  to  the  central  nervous  system  is  less  simple  and  has  only 
recently  been  made  out. 

Most  of  the  nerve  cells  of  the  periphery,  aside  from  those  in  the 
special  sense  organs,  like  the  eye  and  nose,  have  been  considered  to 
belong  to  a  kind  of  special  or  "  sympathetic"  nervous  system. 
There  is  no  harm  in  using  this  nomenclature,  provided  it  is  un- 
derstood that  this  system  is  really  a  part  of  the  rest  of  the  ner- 
vous system  and  not  in  any  sense  an  independent  mechanism. 
The  peripheral  nerve  cells  of  this  system  are  collected  in  two  dis- 
tinct groups*  One  is  made  up  of  the  vertebral  and  cranial  ganglia 
of  the  sympathetic,  and  the  second  of  the  peripheral  ganglia  of  the 
sympathetic,  such  as  the  cells  of  the  plexus  of  Auerbach,  Meissner, 
and  the  various  interstitial  ganglia  of  the  glands  and  muscles. 

I  come  now  to  a  description  of  the  general  arrangement  of  these 
various  nerve  units ;  and  here  I  must  suppose  that  my  reader  has 
a  knowledge  of  the  ordinary  anatomy  of  the  subject. 

The  nerve  cells  of  the  ganglia  on  the  posterior  spinal  roots  fur- 
nish the  best  starting-point  in  an  attempt  to  trace  out  the  connec- 
tions. These  cells  give  off  a  single  process,  which  quickly  divides 
in  a  T  shape.  One  branch  of  the  T  passes  peripherally  through  a 
mixed  spinal  nerve  to  the  skin,  funning  a  sensory  nerve.  The  other 
-  centrally,  enters  the  posterior  spinal  roots,  and  breaks  up 
into  little  filaments,  which  surround  a  nerve  cell  in  the  posterior 
horn  or  analogous  nuclei.  This  forms  the  first  or  outer  sensory  neu- 
ron. The  outer  branch  of  the  spinal  ganglion  cell  which  went  to 
the  periphery  as  a  sensory  nerve  was  its  dendrite,  01  protoplasmic 
process,  which  has  evolved  into  a  sensory  nerve  and  is  cellupetal 
in  function.  The  other  process  is  the  neuraxon  proper  and  it  is  eel- 
lufugal,  carrying  impulses  away  from  the  ganglion  cell  into  the  cord. 

The  next  neuron  begins  as  a  cell  in  the  posterior  horn,  or  in  like 
parts.  It  sends  a  neuraxon  up  the  spinal  cord,  a  collateral  branch 
passes  to  the  cerebellar  cortex,  while  the  direct  fibre  surrounds  a 
cell  in  the  optic  thalamus.  This  forms  the  second  sensory  neuron. 
The  cell  in  the  thalamus  gives  off  a  neuraxon  which  passes  to  the 
gray  matter  of  the  cerebral  cortex,  and  here  it  either  directly  affects 
% 


18 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


the  cells  in  this  region  or  does  it  through  the  medium  of  another 
shorter  neuron,  which  is  called  "  associative. " 

Thus  each  sensory  impulse  from  the  periphery  reaches  the  con- 
scious centres  of  the  brain  by  passing  along  three  or  four  neurons. 
The  primary  neuron  in  all  cases  lies  mainly  outside  the  central 


'A.Neuron  ./' 

Fig.  18.— Diagram  showing  the  Arrangement  of  the  Neurons  or  Nerve  Units  in 
The  Architecture  op  the  Nervous  System.  M.  Neurons  I.  and  II.,  Motor  neurons;  S. 
Neurons  L,  II.,  III.,  sensory  neurons;  A.  Neuron,  associative  or  commissural  neuron. 


nervous  system  and  forms  a  sensory  nerve.  The  sensory  nerves  do 
not  therefore  arise  in  the  cord  or  medulla,  but  have  their  terminal 
nuclei  there. 

The  neurons  of  the  brain  cortex  cannot  yet  be  distinctly  classi- 
fied, and  I  shall  not  attempt  it  here  at  all.  The  matter  will  be 
brought  out  more  fully  in  connection  with  the  anatomy  of  the  brain. 
It  is  sufficient  to  say  that  nerve  units  connect  together  the  cere- 
bellum and  cerebrum  with  the  basal  ganglia,  the  frontal  lobes  and 
the  cerebellum,  the  two  hemispheres  of  the  cerebrum,  and  different 
areas  of  the  cerebral  cortex.  Leaving  out  of  consideration  these 
neurons,  which  are  largely  psychic  in  function,  we  start  with  the 
large  motor  cells  in  the  central  convolutions  of  the  brain.     These 


GENERAL   ANATOMY,  PHYSIOLOGY,  AND    CHEMISTRY.  19 

send  down  neuraxons,  which  pass  into  the  spinal  cord  and  surround 
the  cells  of  the  anterior  horns.  They  form  the  primary  or  central 
motor  neurons.  The  anterior-horn  cells  send  off  neuraxons,  which 
pass  out  through  the  anterior  roots  and  thence  to  the  voluntary 
muscles.  These  are  the  secondary  or  peripheral  motor  neurons. 
Besides  this  there  are  groups  of  cells  in  the  lateral  horns  and  cen- 
tral parts  of  the  spinal  cord  which  send  off  neuraxons  that  also  pass 
through  the  anterior  roots,  but  they  leave  the  cerebro-spinal  nerves 
and  enter  the  vertebral  sympathetic  ganglia.  Here  they  in  part 
surround  the  cells  of  these  ganglia  and  have  their  terminals  there. 
These  sympathetic  ganglion  cells  in  turn  send  neuraxons,  which 
pass  in  the  sympathetic  nerves  to  the  peripheral  ganglia,  where 
they  meet  a  third  group  of  neurons.  They  also  connect  with  the 
other  ganglia  of  their  own  class  and  send  neuraxons  through  the 
posterior  spinal  roots  to  the  cord.  It  is  not  known  with  what 
neurons  higher  up  in  the  nerve  centres  the  lateral-horn  cells  are 
connected,  but  probably  with  cells  in  the  thalamus. 

Such  in  outline  is  the  neuronic  architecture  of  the  nervous  sys- 
tem. I  do  not  attempt  here  to  work  out  the  neurons  of  the  special 
senses,  nor  to  introduce  the  spinal-cerebellar  neuron.  This  will  be 
done  later.  It  is  sufficient  to  say  that  the  studies  in  this  direction 
show  a  marvellous  harmony  as  well  as  beauty  in  nature's  scheme. 

The  neuronic  architecture  is  shown  in  the  accompanying  dia- 
gram (Fig.  18). 

GENERAL  PHYSIOLOGY. 

The  Peripheral  Neurons. — The  nerves  which  run  between  nerve 
centres  and  end  organs  carry  impulses  each  way.  They  are,  there- 
fore, divided  into  the  afferent,  centripetal  or  in-going,  and  efferent^ 
centrifugal  or  out-going.  The  old  division  into  motor  and  sensory 
nerves  will  not  answer,  for  there  are  many  out-going  nerves  which 
are  not  motor.     The  afferent  nerves  are : 

1.  The  sensory,  including: 


Nerves  of   general  (  Pain  nerves  or  pathic  nerves,  heat  and  cold  or  thermic 
sensations.  (      nerves. 

(  Contact, 
'  Tactile,  including  \  Pressure, 
(  Locality. 
Nerves  of  muscular  sense. 

Nerves  of  special  sense    f  smell,  sight,  taste,  hearing, 
and  space. 


Nerves  of  special 
sensation. 


2.  Excito-reflex  nerves. 


20  DISEASES    OF   THE    NERVOUS   SYSTEM. 

The  efferent  nerves  are : 

1.  Motor  nerves,  going  to  voluntary  or  striped  muscles,  heart 
muscle,  smooth  muscle,  including  the  vaso-constrictor  and  dilator 
nerves. 

2.  The  secretory.  These  act  upon  glands.  Impulses  to  the  blood- 
vessels (vasomotor)  generally  accompany  the  secretory  impulses. 

3.  The  trophic. 

4.  The  inhibitory.  These  nerves  control  muscular  movements, 
secretion,  perhaps  also  nutrition. 

We  must  admit  that  afferent  and  efferent  impulses  take  place 
also  between  end  organs  and  certain  (so-called)  sympathetic  ganglia. 
In  other  words,  the  cerebro-spinal  axis  is  not  always  the  centre. 
But  these  subordinate  and  peripheral  centres  are  normally  in  con- 
nection with  the  spinal  cord  and  may  be  influenced  by  it  or  by 
higher  parts. 

The  Central  Neurons. — There  are  intercentral  or  commissural 
neurons,  which  connect  different  parts  of  the  cerebro-spinal  system 
together.  Some  of  these  connect  symmetrical  parts  on  each  side 
together.  They  have  co-ordinating  function.  Others  connect 
higher  with  lower  centres.  These  latter  are  made  up  of  ascending 
and  descending  fibres.  Higher  centres  send  down  impulses  by  the 
latter,  which  may  stimulate  or  inhibit  lower  centres.  In  the  pe- 
ripheval  nervous  system  we  have  also  end  organs.  These  are  deli- 
cate and  in  some  cases  complex  arrangements  of  the  nervous  and 
other  tissue  at  the  periphery  of  the  nerves.  Their  object  is  to  allow 
the  nerves  to  be  irritated  by  special  stimuli  which  would  not  other- 
wise affect  them,  e.g.,  light  or  sound.  Their  object  is  also  the 
proper  utilization  of  efferent  impulses  upon  other  tissues.  There 
are  end  organs,  therefore,  for  both  sensory  or  afferent  and  for  effer- 
ent nerves.  The  end  organs  of  the  afferent  nerves  are — eye,  ear, 
taste  buds,  corpuscles  in  the  Schneiderian  membrane,  various  tactile 
cells  and  bodies,  the  space-sense  organ. 

For  the  efferent  nerves — neuro-muscular  corpuscles  in  the  volun- 
tary muscles,  local  ganglia  about  the  arteries,  local  ganglia  in  the 
glands.  Trophic  end  organs  are  not  known.  In  many  cases  the 
end  organ  is  nothing  but  the  terminal  fibre  of  the  nerve.  This  loses 
both  medullary  sheath  and  neurilemma,  leaving  only  the  axillary 
cylinder.  It  then  splits  up  into  a  terminal  plexus,  or  else  without 
splitting  passes  between  and  around  the  cells  which  it  is  to  affect. 

The  nerves,  centres,  and  end  organs  thus  described  may  be  ar- 
ranged in  mechanisms,  each  mechanism  subserving  a  special  func- 
tion. These  form  the  mechanisms  of  the  nervous  system  proper,  and 
those  of  the  other  organs  of  the  body. 


GENERAL    ANATOMY,   PHYSIOLOGY,  AND    CHEMISTRY.  21 

They  may  be  classified  somewhat  as  follows: 


Cerebro- 
spinal. 


I.   The  psychical  mechanism. 

II.  The  automatic  mechanisms  or  the  mechanism  of  inher- 
ited and  acquired  aptitudes. 

III.  The  sensory  mechanism. 

IV.  The  voluntary  motor  mechanism. 
V.   The  reflex  mechanism. 


f  The  secretory  mechanism. 
Visceral  J  The  trophic  mechanism, 

mechanisms.  j  The  thermic  mechanism. 

i  The  vasomotor  mechanism. 

Various  of  the  simpler  mechanisms  are  combined  to  form  those 
more  complex.  Thus  the  automatic  and  psychical  mechanisms 
embrace  in  their  activity  other  mechanisms  of  lower  grade. 

In  the  same  way  mechanisms  are  combined  for  the  regulation  of 
visceral  functions.  Thus  we  have  the  cardiac,  respiratory,  and 
other  visceral  mechanisms. 

The  Cell-body  of  the  Neuron. — In  the  working  of  these  mechan- 
isms the  nerve-cell  body  is  the  agent  which  generates  the  energy  of 
all  nerve  force,  by  which  impulses  are  started,  controlled,  and  dis- 
tributed. The  larger  the  nucleus  of  the  cell  in  proportion  to  its 
protoplasmic  body,  the  more  stable  or  less  sensitive  the  cell.  The 
larger  the  amount  of  protoplasm  relative  to  the  nucleus,  the  more 
active  the  discharging  power  of  the  cell.  The  nucleus  is  the  part 
of  the  cell  body  which  is  essential  to  constructive  metabolism.  By 
means  of  it  the  cell  builds  up  its  protoplasmic  substance.  When 
thf  nucleus  dies,  the  cell  may  live  or  function  for  a  time,  but  it 
lives  only  on  what  has  been  stored  up ;  it  can  build  no  more.  Nerve 
cells  with  few  exceptions  (spinal  ganglia)  have  no  centrosonu's; 
they  cannot  divide  and  multiply.  Once  dead  they  cannot  be  re- 
stored. 

Tin-  nerve  bines  conduct  impulses  generated  by  nerve  cells. 
These  impulses  travel  at  the  rate  of  about  100  to  120  Eeet  per  sec- 
ond. It  is  less  in  viscera]  nerves  (L'5to30  feet  per  second).  There 
are  no  electrical  currents  in  normal  living  nerves  (Landois)  except 
when  an  impulse  travels  along  them.  Then  an  electrical  current 
travels  along  with  the  impulse.  It  is  called  the  current  of  negative 
variation.  The  irritability  or  excitability  of  a  nerve  is  the  power  it 
lias  of  responding  to  a  stimulus.  When  a  constant  electrical  cur- 
rent is  passed  along  a  nerve  its  irritability  is  modified.  This  modi- 
fied condition  is  called  electrotonus.  When  a  nerve  impulse  passes 
up  an  afferent  nerve  and  is  then  reflected  along  an  afferent  nerve, 
it  is  called  a  reflex  action.     The  time  required  for  this  process  is 


22  DISEASES    OF   THE    NERVOUS    SYSTEM. 

called  the  reaction  time.     This  averages  from  0.125  to  0.2  of  a 
second. 

CHEMISTRY. 

The  specific  gravity  of  nervous  tissue  is  about  1.036;  that  of 
the  brain  is  1.038;  of  the  spinal  cord  and  nerves,  1.034  (Bischoff, 
Krause).  The  reaction  is  alkaline,  but  this  is  lessened  by  activity, 
owing  to  the  development  chiefly  of  lactic  acid.  The  gray  matter 
is  less  alkaline  than  the  white. 

The  nervous  system  has  the  following  composition  (Baum- 
stark,  quoted  by  Hammarsten)  : 

White  Matter.  Gray  Matter. 

Water  in  1,000  parts 695.35  769.97 

Solids. , 304.65  230.03 

Protogonjgrebrin   ^^   | 25n  1008 

Insoluble  albumin  and  connective  tissue 50.02  60.79 

Cholesterin 45. 12  23. 81 

Nuclein 2.94  1.99 

Neurokeratin 18.93  10.43 

Inorganic  salts 5. 23  5. 62 

Water  makes  up  nearly  three-fourths  of  nervous  tissue,  there 
being  more  in  the  gray  than  in  the  white  matter  and  least  in  the 
sympathetic  nerves.  The  inorganic  salts  amount  to  about  .5  per 
cent.  The  largest  single  constituent  is  phosphorus  (Breed)  com- 
bined with  potassium,  sodium,  magnesium,  calcium,  and  iron,  form- 
ing phosphate  salts.  Of  other  constituents  chloride  of  potassium  is 
the  most  important. 

Protogon  is  a  very  complex  substance  of  a  fatty  character,  con- 
taining nitrogen  and  united  with  glycerin-phosphoric  acid  instead 
of  glycerin.  It  is  said  by  some  to  be  made  up  of  two  bodies, 
cerebrin  and  lecethin,  the  latter  containing  an  ammonia  compound 
called  neurin.  Protogon  is  especially  found  in  the  white  matter. 
The  gray  matter  contains  nuclein,  a  very  important  substance  in 
cell  metabolism.  Nuclein  (C29H49N9P3022,  Miescher)  is  composed 
of  nucleic  acid,  a  substance  rich  in  phosphorus  and  a  variable  amount 
of  albumin.  The  gray  matter,  i.e.,  the  nerve  cells,  contains  also 
various  albuminous  substances.  The  nuclein  and  the  allied  sub- 
stance nucleo-albumin  are  called  albuminoids  (Halliburton) .  They 
both  contain  phosphorus  and  are  found  chiefly  in  the  nucleus. 
The  albuminous  substances,  called  also  proteids  by  Halliburton, 
have  little  or  no  phosphorus,  and  make  up  the  most  of  the  cell  body 
or  cytoplasm. 


CHAPTER  II. 

THE   CAUSES  OF  NERVOUS   DISEASES. 

Nervous  diseases  are  produced  in  part  by  predisposing  influences 
which  may  be  likened  to  a  fecund  soil;  in  part  they  are  due  to 
exciting  causes,  which  are  like  the  seeds  dropped  upon  the  soil  in  the 
accidents  of  life. 

Heredity  is  the  most  serious  and  important  of  these  predisposing 
causes,  in  particular  of  those  neuroses  that  are  constitutional  and 
are  not  the  results  of  bodily  accidents.  A  nervous  disease,  how- 
ever, is  rarely  directly  inherited.  Parents  do  not  pass  down  special 
maladies,  but  only  a  general  tendency  to  nerve  disease,  which  is 
not  developed  into  any  distinct  trouble  unless  some  disturbing  cause- 
arises.  Nervous  parents  may  have  children  who  have  unstable, 
over-irritable,  and  inadequate  nervous  systems.  Such  persons  have 
what  is  called  a  neuropathic  constitution  or  diathesis.  This  diathe- 
sis may  be  transmitted  when  the  parents,  though  not  especially 
neurotic,  suffer  from  syphilis,  alcoholism,  and  diseases  of  mal- 
nutrition, like  tuberculosis.  So  far  as  the  offices  of  parentage  go, 
persons  of  great  talent  in  affairs,  or  great  artistic  genius  in  any 
direction,  may  be  counted  as  neurotic  and  are  very  likely  to  have 
children  of  neuropathic  constitution.  This  is  less  apt  to  be  the  case 
when  one  parent  is  of  stable  and  lymphatic  type.  If  persons  having 
not  simply  a  nervous  constitution  but  distinct  nervous  or  mental 
disease  marry,  their  children  are  liable  to  serious  nervous  or  mental 
disease.  The  intermarriage  of  blood  relations  such  as  first  cousins 
does  not  lead  to  neurotic  children  if  the  parents  are  not  both  of  that, 
class,  or  are  of  robust  health  and  dissimilar  temperaments.  In- 
juries or  even  severe  shock  to  the  mother  during  the  early  months 
of  pregnancy  sometimes  leads  to  nervousness  in  the  offspring.  The 
mother  transmits  neuroses  more  often  than  the  father.  There  are 
certain  rare  nervous  diseases  which  appear  in  different  branches 
and  members  of  a  family,  such  as  an  uncle,  cousin,  nephew,  and 
son.  These  diseases  may  pass  also  by  direct  inheritance  from 
parent  to  child,  or  may  skip  a  generation.  They  are  called  "  family 
diseases,"  and  are  of  the  nature  of  congenital  defects,  like  webbed 
fingers  or  clubfoot. 

Morbid  traits  that  have  become  fixed  in  a  family  reappear  at 


24  DISEASES    OF   THE    NERVOUS    SYSTEM. 

about  the  same  age  in  the  descendants.  If  these  traits  or  tendencies 
are  disappearing  from  the  family,  however,  they  appear  later  in  life 
with  each  successive  generation  in  the  descendants.  If  they  are 
becoming  more  intensified,  they  develop,  at  an  earlier  age  in  the  suc- 
cessive descendants.  Thus  migrainous  attacks  which  have  existed 
in  a  family  usually  appear  between  twelve  and  fifteen.  If  now 
they  do  not  develop  till  the  age  of  thirty  it  shows  that  the  mi- 
grainous taint  is  dying  out. 

When  a  nervous  disease  develops  in  a  grandchild,  having  skipped 
a  generation,  it  is  called  a  manifestation  of  atavism.  Atavism  is 
a  very  slight  factor  in  nervous  diseases,  and  rarely  goes  back  more 
than  two  generations. 

Degeneration  is  the  name  given  to  a  condition  in  which  there  is 
a  morbid  deviation  from  the  normal  average.  It  is  almost  always 
an  inherited  state,  and  the  word  degenerate  is  often  used  to  indicate 
a  person  who  has  a  hereditary  neuropathic  constitution.  Degen- 
eracy in  a  moderate  degree  often  accompanies  great  mental  powers, 
especially  of  the  artistic  kind,  and  it  is  almost  invariably  associated 
with  genius.  It  is  quite  compatible  with  mental  soundness  and  a 
fair  degree  of  physical  health.  Those  who  have  unusual  mental 
gifts  and  degenerate  characteristics  are  called  superior  degenerates. 
The  criminal  and  the  insane  and  erratic  and  eccentric  persons  of 
weak  judgment  have  also  the  neurotic  constitution,  and  are  called 
inferior  degenerates.  The  weak  minded,  imbecile,  and  idiots  form 
the  lowest  class  of  degenerates,  and  are  called  the  debiles.  The 
degenerate  tends  to  sterility,  and  if  two  degenerates  many,  and 
have  children,  their  children  are  likely  to  be  more  abnormal  than 
the  parents.  Degenerate  families  tend  to  die  out.  But  this  ten- 
dency can  be  avoided  by  the  infusion  of  sound  blood. 

Age. — In  infancy  and  early  childhood,  nervous  diseases  are 
rather  frequent  on  account  of  the  accidents  at  birth,  the  liability 
to  infectious  fevers,  and  malnutrition,  and  the  high  degree  of  sen- 
sitiveness of  the  yet  immature  nervous  system.  Still,  a  carefully 
watched  infant  is  relatively  safe.  Motor  disorders,  such  as  paraly- 
ses, convulsions,  and  chorea,  are  much  the  more  common  troubles. 
At  the  time  of  puberty  sensory  disorders,  such  as  headache  and 
migraine  appear,  and  often  epilepsy,  hysteria,  and  disorders  of  sleep. 
Hereditary  tendencies  to  nervous  disease  also  begin  to  develop  at 
this  time  or  a  little  later.  At  the  period  of  adolescence,  the  mal- 
adies already  mentioned  also  may  be  brought  out ;  but  in  addition 
neurasthenic,  morbid  sexual,  hypochondriacal,  and  insane  tenden- 
cies are  seen.  From  maturity  to  the  time  when  degenerative 
changes  begin,  forty  to  forty-five,  the  individual  suffers  from  those 


THE   CAUSES   OF    NERVOUS   DISEASES.  25 

nervous  disorders  brought  ou  by  accidents,  injuries,  prostrating 
attacks  of  sickness,  overstrain,  infections,  indulgence  in  alcohoi 
and  narcotics,  and  the  abuse  of  the  bodily  functions.  At  and  after 
the  climacteric,  one  sees  oftenest  such  maladies  as  result  from  vas- 
cular disease,  apoplexies,  softening,  severe  forms  of  neuralgia,  and 
spasm. 

Sex. — Sensory  and  functional  disorders  are  more  frequent  in 
women ;  motor  and  organic  disorders  more  frequent  in  men. 

Condition  and  Occupation. — No  general  facts  will  be  laid  down 
here.  Celibates,  however,  it  may  be  said,  suffer  more  from  ner- 
vous disorders  than  married  people.  It  will  be  shown  later  that 
certain  occupations  entail  special  nervous  disorders  and  that  in- 
door life  promotes  functional  nervous  diseases.  The  influence 
of  education  in  the  development  of  nervous  diseases  is  very 
great,  but  it  can  be  best  considered  in  connection  with  special 
diseases. 

Habits. — Excessive  indulgence  in  alcohol  is  a  most  prolific  cause 
of  nervous  disease,  chiefly  by  the  action  of  this  substance  on  the 
blood-vessels  and  the  stomach.  Excesses  in  eating,  in  tea-drinking, 
irregularity  in  sleeping,  and  bad  habits  of  working  predispose  to 
nervous  disease.  Sexual  excesses  are  usually  the  result  rather  than 
the  cause  of  nervous  disorders.  They  are  the  evidence  of  mental 
more  than  of  nervous  weakness. 

Climate  and  Civilization. — Nervous  diseases  are  most  frequent 
in  temperate  climates,  and  in  those  which  are  dry  and  elevated. 
They  increase  with  the  progress  of  civilization  and  the  greater 
strain,  complexity,  and  luxury  of  modern  social  life.  Those  or- 
ganic nervous  diseases  which  are  largely  dependent  on  vascular  dis- 
ease are  frequent  in  the  poorer  classes,  among  whom  syphilis, 
alcoholism,  and  bad  feeding  prevail.  Functional  and  degenerative 
disorders  are  frequent  in  the  higher  classes.  Nervous  diseases, 
if  Ave  except  those  of  the  degenerative  type,  prevail  more  in  urban 
populations. 

Diathesis. — The  rheumatic  and  gouty  diatheses  predispose  to 
nervous  troubles,  more  especially  those  which  are  of  a  peripheral 
and  functional  nature.  Lithsemia,  a  condition  in  which  the  prod- 
ucts of  tissue  waste  are  not  properly  oxidized  and  eliminated,  has 
a  similar  influence. 

Trauma  ami  Shock. — Exhausting  hemorrhages  and  trauma  may 
be  the  direct  cause  of  or  may  predispose  to  nervous  disease.  Trauma 
and  shock  may  cause  functional  diseases  such  as  neurasthenia,  or 
may  lead  to  the  development  of  insanity  or  indirectly  to  degenera- 
tive organic  disease.     Mental  shock,  and  especially  a  fright,  oftener 


26  DISEASES   OF   THE    NERVOUS   SYSTEM. 

than  severe  bodily  injury,  leads  to  the  development  of  functional 
neuroses. 

Infections. — In  comparison  with  their  frequency,  the  infective 
fevers  are  not  great  factors  in  producing  nervous  disease,  but  prac- 
tically they  often  play  an  important  part.  Scarlet  fever  is  the  most 
dangerous  disorder  in  this  respect.  Measles  perhaps  ranks  next; 
then  follow  influenza,  diphtheria,  typhoid  fever,  and  pertussis. 
Among  chronic  infections  syphilis  ranks  first ;  malaria,  the  pellagra, 
and  beriberi  are  also  to  be  mentioned. 

Poisons. — Alcohol,  tea,  coffee,  and  lead,  mercury,  copper,  and 
arsenic,  are  to  be  placed  among  the  frequent  causes  of  nervous  dis- 
ease. Alcohol  in  excess  is  justly  credited  with  exerting  the  most 
sinister  influence  on  the  nervous  system,  even  leading  to  an  acquired 
state  of  degeneration. 

Reflex  Causes. — Among  other  causes  are  local  disease  of  viscera, 
such  as  renal,  uterine,  and  ovarian  diseases,  dyspeptic  and  liver 
disorders,  visual  and  auditory  troubles.  Keflex  irritations  are  dis- 
tinctively exciting  causes,  and  with  few  exceptions  they  cannot 
cause  a  nervous  disease  unless  there  is  a  predisposition  to  it.  They 
may,  however,  cause  many  distressing  nervous  symptoms,  such  as 
pain,  spasm,  and  even  convulsion. 


CHAPTER  III. 

GENEEAL   PATHOLOGY. 

The  nervous  system  is  composed  of  nerve  cells  and  nerve  fibres, 
forming  neurons,  connective  tissue,  the  neuroglia,  blood-vessels, 
and  lymphatics.  Its  disorders  involve  one  or  more  of  the  above 
tissues. 

The  following  is  a  list  of  the  forms  of  disease  which  affect  the 
nervous  system : 

1.  Malformations;  incomplete  development,  or  agenesis ;  defec- 
tive development,  or  dysgenesis. 

2.  Hyperaemia,  anaemia,  hemorrhage,  oedema,  and  arterial  and 
venous  diseases. 

3.  Inflammations. 

4.  Degeneration  and  atrophy,  softening,  sclerosis,  gliosis. 

5.  Tuberculosis  and  syphilis. 

6.  Tumors  and  parasites. 

7.  Nutritive  and  functional  disorders,  including  disorders  asso- 
ciated with  metabolic  and  glandular  defect,  such  as  acromegaly  and 
exophthalmic  goitre. 

Inflammation. — The  pathology  of  most  of  the  above  types  of 
diseases  will  be  given  elsewhere,  and  does  not  call  for  discussion 
here.  It  is,  however,  of  the  utmost  importance  that  the  student 
have  a  clear  understanding  of  the  nature  of  inflammation  and 
degeneration  as  they  affect  the  nervous  tissue.  Inflammation  is 
a  morbid  process  which  has  to  deal  primarily  with  blood-vessels, 
lymphatics,  and  connective  tissue.  Inflammation,  teleologically, 
is  the  reaction  of  the  organism  to  an  irritant.  "Wherever  there  is 
inflammation,  there  is  irritation.  The  irritant  in  inflammation  is 
practically  always  the  product  of  microbic  action  or  some  irritat- 
ing product  of  tissue  change.  Without  some  microbic  or  tissue 
irritant  there  can  be  no  inflammation.  We  make  this  exception 
only:  that  certain  chemical  substances,  such  as  alcohol,  arsenic, 
and  lead,  may  at  times  excite  a  form  of  inflammation,  which  is, 
however,  probably,  primarily  a  degenerative  or  destructive  proc- 
cess.  Inflammation,  when  the  irritant  is  removed,  tends  to  sub- 
side. It  is  a  regressive,  not  a  progressive,  process.  Bearing  these 
facts  in  mind,  it  will  be  found  that  inflammations  of  the  nervous 
tissues  never  or  very  rarely  occur  without  the  presence  of  some  mi- 


28 


DISEASES    OF   THE   NERVOUS   SYSTEM. 


crobe  or  some  destructive  process  whose  irritant  products  excite  in- 
flammatory reaction. 

Inflammations  may  be  divided  into  the  (1)  exudative  and  the 
(2)  productive  forms  (Delafield).  The  exudative  inflammations 
may  be  simple;  without  necrosis,  with  necrosis;  purulent;  purulent 
and  necrotic. 

1.  Simple  exudative  inflammation  is  accompanied  with  conges- 
tion, stasis,  emigration  of  white  corpuscles,  and  perhaps  diapedesis 
of  red  cells,  transudation  of  blood  serum,  and  formation  of  fibrin, 
the  total  result  being  an  exudate  containing  white  blood  cells,  now 
called  pus  cells,  and  fibrin  in  varying  proportions.  There  is,  in 
some  cases,  no  destruction  of  tissue;  and  on  subsidence  of  the 
inflammation  the  tissue  returns  to  its  normal  condition.  In  other 
cases  the  inflammatory  action  destroys  some  of  the  nerve  tissue. 

In  purulent  inflammation  there  is  a  great  accumulation  of  pus 
cells  and  less  relatively  of  fibrin. 

If  the  tissue  is  destroyed,  it  is  a  purulent  and  necrotic  inflam- 
mation. 

In  some  exudative  inflammations  there  is  increase  of  connective 
tissue  from  the  start,  and  the  process  continues  till  the  inflamma- 
tion subsides.  Most  exudative  inflammations  are  acute  or  subacute. 
Inflammatory  cedema  is  a  form  of  exudative  inflammation. 

2.  Productive  or  proliferative  inflammation  is  a  process  in  which 
there  are  little  congestion  and  exudation,  while  new  connective  tis- 
sue is  slowly  formed.  Productive  inflammation  is  usually  chronic ; 
tuberculous  and  syphilitic  processes  are  varieties  of  productive  in- 
flammation. 

The  principal  poisons  which  may  cause  chronic  productive  in- 
flammations are  alcohol,  lead,  and  arsenic.  Certain  irritating  auto- 
toxsemic  agents,  such  as  occur  in  gout,  rheumatism,  diabetes,  and 
states  of  inanition,  appear  able  at  times  to  cause  productive  inflam- 
mations. 

Classification  op  Inflammations. 


Form. 


Simple    exudative,     with    or 

without  necrosis. 
Purulent,    with    or    without 

necrosis. 

Productive  or  proliferative. . 


Cause. 


Microbic  or  toxic. 

Microbic 

Microbic 

Microbic  or  toxic. 


Example. 


Meningitis. 

Poliomyelitis. 

Meningitis  and  encephalitis. 

Acute  purulent  myelitis. 
Chronic  meningitis. 

Leprous  neuritis. 


Degenerations  and  Scleroses. — By  degeneration  is  meant  in 
pathology  a  gradual  death  of  the  nerve  cells  and  fibres,  or  in  other 


GENERAL   PATHOLOGY.  29 

words  of  the  parenchyma  of  the  organ.  The  cells  swell  up,  be- 
come granular  and  fatty,  and  then  either  break  up  and  become 
absorbed  or  enter  into  a  condition  of  a  dead  coagulum  (coagulation- 
necrosis).  Degenerations  may  be  acute  or  chronic,  primary  or  sec- 
ondary. 

Acute  degeneration  causes  a  condition  known  as  softening  or 
necrosis.  It  is  due  to  cutting  off  of  vascular  supply,  direct  injury, 
and  to  necrotic  and  inflammatory  poisons.  Acxite  degeneration  may 
be  followed  by  a  reparative  process,  which  is  called  a  reparative  or 
reactive  inflammation,  and  which  ends  perhaps  in  producing  a 
cicatrix  or  sclerosis. 

Chronic  degeneration  is  accompanied  and  followed  by  a  prolif- 
erative process  which  results  in  the  production  of  connective  tissue 
and  sclerosis. 

Sclerosis  is  a  process  of  connective-tissue  proliferation,  as  a 
result  of  which  the  normal  or  injured  parenchyma  is  supplanted  by 
fibrous  tissue.  The  word  sclerosis  is  usually  employed  in  describ- 
ing degenerative  diseases,  though  it  indicates  the  result  rather  than 
the  primary  nature  of  the  process.  In  the  nervous  system  there  is 
often  an  increase  or  proliferation  of  neuroglia  tissue  in  the  proc- 
esses of  degeneration.  Exactly  how  large  a  factor  this  is  cannot 
yet  be  said. 

A  primary  degeneration  is  one  in  which  the  process  is  due  to 
inherent  defect  in  nutrition  or  to  some  poison  acting  directly  on  the 
cell  or  fibre. 

A  secondary  degeneration  is  one  that  is  due  to  a  cutting  off  of 
nerve  fibre  or  cell  from  its  trophic  centre,  or  to  an  injury  or  shutting 
off  of  its  vascular  supply.  Ordinarily,  in  speaking  of  secondary 
degenerations  one  refers  to  those  due  to  the  first-mentioned  class. 
Practically,  primary  and  secondary  degenerations  often  occur  in  the 
same  disease. 

Degenerations.  Forms.  Examples. 

(  Myelomalacia. 
(  Primary -|  Progressive  muscular  atrophy. 

Aentc  and  Chrome  \  <  I"*"™"*  »««^ 

{  Secondary  and  mixed  j  g££$gft  solcrosi, 

Degenerations  are  caused  by  certain  poisons,  such  as  arsenic, 
phosphorus,  lead,  and  the  poisons  of  infectious  disease.  Degenera- 
tions also  result  from  obliterating  arteritis,  such  as  occurs  in  old  age 
or  from  humoral  poisons.  Degenerations  sometimes  are  due  ap- 
parently to  an  inherent  defect  in  the  cell  nutrition — a  premature 
death   of  it;    also  to  causes  yet  unknown.     The  question  as   to 


30  DISEASES   OF   THE    NERVOUS   SYSTEM. 

whether  certain  scleroses  are  forms  of  productive  inflammation  or  oi 
chronic  degeneration  is  one  that  has  been  much  debated  in  the  past. 
It  is  quite  certain  now  that  the  so-called  chronic  inflanimations  of 
the  nervous  centres  are  really  degenerative  processes,  and  that  the 
primary  trouble  is  in  the  parenchyma,  and  not  in  the  connective 
tissue. 

Gliosis. — It  is  contended  by  some  French  pathologists  (Chaslin, 
Dejerine)  that  some  of  the  chronic  degenerative  diseases  are  the 
result  of  a  proliferation  of  neuroglia,  not  of  connective  tissue.  This 
process  is  called  gliosis.  Its  existence  is  not  yet  satisfactorily 
established. 

Nutritive  and  Functional  Disorders. — Under  this  head  are  in- 
cluded defects  due  to  disorders  of  the  blood  and  blood  glands,  to 
defects  in  metabolism,  to  poisons,  extrinsic  and  autochthonous,  and 
to  local  diseases. 

In  conclusion  some  fundamental  peculiarities  of  the  nervous 
tissue  may  be  noted  here. 

Nerve  cells  once  destroyed  never  develop  again. 

The  same  is  true,  though  not  so  absolutely,  for  the  nerve  fibres 
running  in  the  central  nervous  system.  Peripheral  nerves  may 
grow  again  when  cut  or  destroyed.  They  always  grow  from  their 
trophic  centre.  Nerve  tissue  in  brain,  cord,  or  periphery  can  never 
be  sutured  so  that  it  will  functionally  unite  by  direct  union.  There 
are  a  few  apparent  exceptions. 

A  further  peculiarity  of  nervous  tissue  is  that  it  is  dependent 
for  its  integrity  upon  two  things,  blood  supply  and  trophic  in- 
fluences. The  nerve  cell  is  solely  dependent  on  a  proper  supply  of 
blood,  and  dies  when  this  is  withdrawn.  But  the  neuraxon  is  more 
dependent  on  the  trophic  influence  of  the  cell  of  which  it  is  a  pro- 
longation. It  dies  when  cut  off  from  its  cell,  but  it  can  get  along 
for  a  time  with  but  little  direct  blood  supply.  On  the  other  hand, 
if  the  neuraxon  is  injured  it  reacts  on  the  cell,  leading  to  a  partial 
but  curable  degeneration  of  the  cell  body. 


CHAPTER   IV. 

GENERAL   SYMPTOMS. 

When  the  nervous  system  is  disordered  it  produces  various 
symptoms,  which  are  classified  and  receive  names  according  to  the 
parts  affected  and  the  kind  of  change  present.  The  general  name 
given  to  any  kind  of  morbid  nervous  state  is  neurosis  and  the  gen- 
eral name  for  any  morbid  mental  state  is  psychosis.  When  the 
neurosis  affects  the  motor  sphere,  whether  in  the  brain  or  cord  or 
nerves,  it  is  a  motor  neurosis,  or,  more  technically,  a  kinesio-neuro- 
sis ;  when  the  sensory  parts  are  disordered  we  have  a  sensory  neu- 
rosis, or  sesthesio-neurosis.  In  the  same  way  we  have  trophic, 
thermic,  vasomotor,  and  secretory  neuroses. 

The  symptoms  of  nervous  disease  are  further  divided  in  accor- 
dance with  the  kind  of  disturbances  present.  Now  a  function  can  only 
be  disordered  in  three  ways.  It  may  be  exaggerated,  lessened,  to 
the  point  perhaps  of  entire  loss  of  function,  or  it  may  be  perverted. 
In  order  to  indicate  this  certain  Greek  prefixes  are  used.  They 
are  "  hyper, "  which  means  excess ;  "  hypo, "  meaning  diminution ;  "  a" 
or  "  an, "  indicating  entire  loss ;  and  "  para, "  meaning  perverted. 
Thus  we  have,  for  example,  hyperesthesia,  or  excessive  sensibility; 
anaesthesia,  or  loss  of  sensibility ;  and  paraesthesia,  which  means  per- 
verted sensibility. 

Finally,  nervous  symptoms  are  often  spoken  of  as  objective 
or  subjective.  The  former  are  those  symptoms  which  can  be  seen 
or  directly  noted  by  the  physician  without  depending  on  the  patient's 
statements.  The  subjective  symptoms  are  those  which  are  felt  by 
the  patient,  but  give  no  outward  sign.  Thus  headache  is  a  subjec- 
tive symptom,  paralysis  is  an  objective  one. 

So  far  we  have  been  grouping  together  only  like  kinds  of  symp- 
toms; but  it  happens  that  many  nervous  diseases  may  have  quite 
different  kinds,  some  being  motor,  some  trophic  or  sensory.  Thus 
nervous  diseases  practically  are  to  a  considerable  extent  classified 
simply  on  the  basis  of  the  part  of  the  nervous  system  diseased ;  and 
we  have  spinal-cord  and  brain  diseases,  gastric  and  sexual  neuro- 
ses, and  so  on. 

Nervous  symptoms,  however,   are  always  grouped  together  in 


32  DISEASES    OF   THE    NERVOUS   SYSTEM. 

accordance  with  the  physiological  function  disturbed.     So  that  we 
have  the  following  tabulation  (see  also  Fig.  19)  : 

1.  Mental  and  cerebral,  forming  psychoses. 

2.  Motor  and  reflex,  forming  kinesio-neuroses. 

3.  Sensory,  forming  festhesio-neuroses. 

4.  Trophic,  forming  tropho-neuroses. 

5.  Vasomotor  and  thermic,  forming  angio-neuroses  and  thermo- 
neuroses. 

6.  Secretory,  forming  secretory  neuroses. 

Combinations  of  these  groups  of  symptoms  may  affect  various 
organs.  They  are  called  mixed  neuroses.  Combinations  of  mental 
and  nervous  symptoms  form  psychoneuroses. 

The  particular  symptoms  which  nervous  diseases  cause  will  be 
described  and  recorded  under  the  several  heads  given  above. 

1.  The  mental  symptoms  include  all  those  found  in  insanity, 
idiocy,  and  imbecility,  and  will  not  be  given  in  detail  here.  The 
common  symptoms  met  with  by  the  neurologist  are  mental  irrita- 
bility, depression,  emotional  excitement,  morbid  fears,  volitional 
weakness  and  lack  of  self-control,  persistent  or  fixed  ideas,  weak- 
ness of  memory  and  of  power  of  concentration,  and  a  tendency  to 
hypnotic  and  somnambulistic  states. 

Certain  symptoms  due  to  disturbance  of  brain  function  are  often 
called  cerebral,  as  distinguished  from  mental.  They  are :  vertigo, 
disorders  of  equilibrium,  insomnia,  somnolence,  stupor,  coma. 
Headache,  head  pressure,  and  similar  feelings  are  also  often  de- 
scribed under  the  head  of  cerebral  symptoms. 

2.  Motor  Symptoms. — The  symptoms  of  disordered  motility  are 
as  follows : 

A.  Symptoms  of  exaggerated  motility,  or  hyperkineses. 

a,  fibrillary : 

Tremor :  (  intentional, 

b,  tremor  proper :  -  passive, 

(  constant. 

!  tonic, 
clonic, 
co-ordinate. 

Choreic  and  choreiform  movements,  athetosis. 
Muscular  tension  and  contracture. 
Forced  and  associated  movements. 
Exaggerated  reflexes  and  clonus. 

B.  Symptoms  of  lessened  motility. 
Paralysis  and  paresis,  amyasthenia. 
Loss  of  reflexes,  superficial  and  deep. 


GENERAL   SYMPTOMS.  33 

The  particular  characteristics  of  these  different  symptoms  -will 
be  best  shown  in  the  description  of  the  special  diseases,  but  a  brief 
account  will  be  given  here. 

Tremor  is  the  result  of  a  disorder  in  the  tonic  innervation  of 
muscles.  Muscles  are  kept  normally  in  a  state  of  slight  tension  by 
rhythmical  impulses  passing  down  at  the  rate  of  about  twelve  per 
second.  When  the  rhythm  and  force  of  these  normal  impulses  are 
interfered  with  we  have  tremor.  The  simplest  form  of  tremor  is 
one  in  which  the  normal  tonic  impulses  have  an  apparently  exagger- 
ated force.  This  causes  a  fine  tremor  of  eight  to  twelve  vibrations 
per  second.  When  there  is  an  interruption  to  some  of  the  impulses 
we  have  a  coarse  tremor.  Here  the  vibrations  are  five  to  eight  per 
second.  It  is  caused  by  a  partial  or  complete  dropping  out  of  the 
alternate  impulse.  Various  technical  names  are  used  in  describing 
the  tremors.     We  have  the  fine  and  coarse,  as  described. 


\\Q  Psycho 


W  ne  sloneu  rose  s 
Assthesioneuroses 

Secretory  &iropB& 

\aso-  motor 

Fig.  19.— Diagram  illustrating  the  Principle  of  the  Classification  of  Nervous 

Symptoms. 

Intention  tremor  is  one  that  occurs  on  voluntary  movement,  and 
is  opposite  in  kind  to  the  passive  tremor  or  tremor  of  rest,  which 
decreases  or  ceases  on  voluntary  effort.  Tremor  is  sometimes  of  a 
coarse,  jerky,  and  inco-ordinate  character,  and  these  words  are  then 
used  to  indicate  it. 

Fibrillary  tremor  is  a  fine  twitching  of  the  individual  strands 
or  parts  of  muscles,  and  occurs  usually  when  they  are  wasting  from 
lack  of  neuro-trophio  influence. 

Convulsions  consist  of  abnormal  and  exaggerated  muscular  con- 
tractions occurring  in  rapid  succession.  Convulsions  may  be  clonic, 
i.e.,  the  muscles  rapidly  and  alternately  contract  and  relax  in  an 
exaggerated  and  irregular  way;  or  they  may  be  tonic,  /.<•.,  con- 
tracted steadily  and  continuously.  When  a  tonic  muscular  contrac- 
tion is  painful  it  is  called  cramp.  Convulsions  may  be  co-ordinate. 
In  this  case  the  patient  moves  the  limbs  and  body  in  a  more  or  less 
purposeful  way.  He  throws  himself  about  the  bed,  jumps,  kicks, 
3 


34  DISEASES    OF   THE   NERVOUS   SYSTEM, 

strikes,  tears  the  clothes,  etc.  Convulsions  are  usually  accompanied 
with  loss  of  consciousness. 

Choreic  movements  are  sudden  jerking,  twitching  movements  of 
different  groups  of  muscles.  The  movements  are  purposeless  and 
are  not  under  control  of  the  will.  Convulsive  tic  is  a  form  of  choreic 
movement  confined  to  certain  groups  of  muscles  which  work  together 
for  a  common  purpose,  like  those  of  the  face,  or  eyes,  or  larynx. 
The  movements  in  the  "  tics"  are  more  definite  in  character  and  are 
limited  to  muscles  physiologically  grouped  for  a  definite  function. 
Thus  we  have  tics  of  the  muscles  of  expression,  or  of  respiration,  or 
speech,  or  locomotion. 

Athetosis  is  a  name  given  by  Hammond  to  a  peculiar  form  of 
movement  characterized  by  slow,  successive  flexion,  extension,  pro- 
nation, and  supination  of  the  fingers  and  hand  and  arm,  or  of  anal- 
ogous movement  of  the  toes  and  feet.     The  motion  rarely  ceases  in 


Ad 

Fig.  20.— The  Hand  in  Athetosis  (StrOmpell). 

waking  hours  except  for  a  short  time.  The  contractions  are  forci- 
ble, steady,  and  even,  and  sometimes  painful.  The  hand  assumes 
characteristic  positions  (Fig.  20). 

A  contracture  is  a  tonic  muscular  spasm  of  long  duration,  i.e., 
days  or  months.  A  contracture  may  be  functional  or  organic ;  and 
in  order  to  test  this,  one  must  find  whether  it  ceases  during  sleep  or 
under  an  anaesthetic;  if  so,  it  is  functional  (see  Hysteria). 

In  forced  movements  the  patient  suddenly  and  involuntarily  is 
thrown  forward,  sideways,  or  whirled  about  in  various  ways. 

Associated  movements  are  those  which  occur  involuntarily  in  a 
limb  or  muscle  at  rest  when  the  corresponding  limb  or  muscle  is 
moved  on  the  opposite  side.  Thus  in  hemiplegia  the  movement  of 
the  normal  arm  may  excite  a  movement  in  the  one  paralyzed.  The 
patient  is  given  a  piece  of  chalk  in  each  hand,  and  each  hand  is 
placed  upon  a  blackboard  lying  on  the  table ;  attempts  at  drawing 
lines  with  the  sound  arm  cause  movements  of  a  similar  kind,  but 
less  perfect,  on  the  paralyzed  side. 


GEXERAL   SYMPTOMS. 


35 


Paralysis  or  akinesis  is  a  loss  of  motor  power.  Monoplegia  is  a 
condition  in  which  one  limb  is  paralyzed ;  hemiplegia  one  in  which 
one-half  the  body  is  paralyzed;  and  paraplegia  one  in  which  the 
two  lower  limbs  are  affected.  Sometimes  a  double  hemiplegia  or 
diplegia  occurs.  The  term  paralysis  is  sometimes  used  to  indicate 
loss  of  any  kind  of  function,  as  paralysis  of  sensation  or  secretion. 

Paresis  is  a  term  used  to  indicate  a  partial  paralysis.  It  is  not 
to  be  confounded  with  the  term  general  paresis,  which  is  a  form  of 
insanity. 

w 


Fig.  21.— Showing  the  Course  of  the  Impulse  in  a  Simple  Reflex  Action. 

The  Reflexes. — When  an  impulse  started  in  an  afferent  nerve 
reaches  the  spinal  cord  or  medulla  and  is  thence  reflected  upon  an 
efferent  nerve,  the  result  is  called  a  simple  reflex  action  (Fig.  21). 
The  process  is  an  involuntary  one.  It  ordinarily  occupies  one-tenth 
to  one-twelfth  of  a  second.  The  afferent  nerve  may  be  an  ordinary 
cutaneous  sensoiy  nerve,  or  it  may  be  a  special  nerve  whose  func- 
tion is  to  excite  reflex  action.  These  latter  nerves  are  called  excito- 
reflex.     This  kind  is  principally  supplied  to  the  viscera. 

In  neurology  we  have  to  do  with  four  kinds  of  reflexes; 

The  skin  or  superficial  reflexes. 

The  tendonous  or  deep  reflexes. 

The  visceral  reflexes. 

Idiopathic  muscle  reflex. 

All  these  may  be  exaggerated,  lessened,  or  absent.  Further  de- 
scription of  these  reflexes  will  be  given  under  the  head  of  diagnosis. 


36  DISEASES   OF   THE   NEKYOUS   SYSTEM. 

3.  Sensory  Symptoms. — The  sensory  functions  include  all  those 
belonging  to  the  nerves  of  general  and.  special  sensation.  Sensory 
nerves  have  a  part  in  reflex  action  and  in  the  inhibition  of  motor 
and  other  functions.  The  nerves  of  special  sense  when  deranged 
show  various  phenomena,  which  will  be  described  in  more  detail 
later.  In  general  there  may  be  depression  or  loss,  increase  or  per- 
version of  their  function.     In  accordance  with  this  we  have : 

Ancesthesia  which  is  a  loss  of  tactile  sensibility. 

Analgesia,  a  loss  of  sensibility  to  pain. 

Thermo-ancesthesia,  a  loss  of  sensibility  to  temperature.  There 
may  be  loss  of  cold-sense  or  of  heat-sense,  or,  as  is  usually  the  case, 
of  both  senses. 

The  term  anaesthesia  is  often  used  with  a  general  meaning  to 
indicate  loss  of  all  forms  of  sensibility.  Anaesthesia  in  this  sense 
is  a  symptom  referred  to  the  skin,  bones,  mucous  membranes,  spe- 
cial senses,  or  viscera.  The  muscles  have  two  kinds  of  sensibility, 
a  sensibility  to  pain  and  a  special  muscle  sense.  Anaesthesia  of  the 
pain  sense  of  muscle  is  called  loss  of  muscular  sensibility  or  muscu- 
lar analgesia.  Anaesthesia  of  the  special  muscle  sense  is  one  of  the 
factors  in  causing  a  symptom  known  as  ataxia. 

Ataxia  is  a  symptom  clue  to  loss  of  the  special  sensibility  of  the 
muscles,  articular  surfaces,  and  tendons.  This  special  sense  in- 
forms the  individual  of  the  degree  and  strength  of  muscular  move- 
ments, and  by  it  definite  and  co-ordinated  movements  are  made 
possible.  The  weight  of  objects  and  position  of  the  limbs  are  also 
determined  by  it.  In  static  ataxia  there  is  loss  of  the  power  to 
preserve  perfectly  the  equilibrium  when  standing.  It  is  clue  to  the 
form  of  anaesthesia  just  referred  to.  In  locomotor  or  motor  ataxia 
there  is  loss  of  power  to  co-ordinate  the  limbs  properly  in  motion. 
In  these  conditions  there  is  also  usually  a  loss  of  power  to  appreci- 
ate weights  or  the  position  of  the  limbs.  The  term  muscular  anaes- 
thesia, however,  is  often  used  to  indicate  these  latter  symptoms. 
Cerebellar  ataxia  is  a  form  of  inco-ordination  due  to  disease  of  the 
central  organ  of  equilibration,  viz.,  the  cerebellum. 

Astereognosis  is  a  symptom  indicating  a  loss  of  ability  to  appre- 
ciate the  form  or  shape  of  objects  felt. 

Hypercesthesia  is  an  excessive  sensibility  to  touch,  contact,  and 
other  stimuli. 

Hyperalgesia  is  excessive  sensibility  to  pain,  and  is  nearly  iden- 
tical with  tenderness. 

Dysesthesia  is  an  abnormal  sensation,  such  as  a  "thrill"  or  feel- 
ing of  discomfort  produced  by  ordinary  tactile  or  painful  impressions. 


GENEEAL   SYMPTOMS.  3? 

Parcesthesia  is  a  term  applied  to  all  the  morbid  general  sensa- 
tions except  pain.  The  paresthesias  include  such  feelings  as  numb- 
ness, prickling,  formication,  flushing,  burning,  itching,  coldness, 
tickling,  feelings  of  weariness,  exhaustion,  various  peculiar  visceral 
sensations.  Ordinarily  in  speaking  of  parsesthesiae,  however,  we 
refer  to  such  feelings  as  numbness,  prickling,  and  creeping. 

Delayed  sensation  is  a  symptom  in  which  an  appreciable  time 
exists,  usually  one  or  more  seconds,  between  the  time  of  applying  a 
stimulus  and  its  appreciation  in  consciousness.  Normally  a  tactile 
sensation  can  be  felt  and  responded  to  in  less  than  one-tenth  of  a 
second. 

Transferred  or  referred  or  reflex  sensations  are  those  in  which 
the  irritation  is  made  at  one  point  and  felt  at  another.  Thus  an 
irritation  in  the  stomach  causes  a  pain  felt  in  the  forehead.  The 
whole  class  of  so-called  reflex  pains  are  really  transferred  sensations, 
since  in  reality  there  is  no  reflex  action  in  the  process,  as  will  be 
seen  later.  Allochiria  is  a  peculiar  form  of  transferred  sensation,  in 
which  an  irritation  applied  on  one  side  of  the  body  is  referred  to  a 
corresponding  point  on  the  opposite  side. 

4.  Trophic  Disorders. — These  are  called  tropho-neuroses.  They 
consist,  so  far  as  relates  to  neurology,  chiefly  of  hypertrophy  and 
atrophy  of  nerves,  muscle,  cutaneous  and  mucous  tissues,  joint  de- 
g 'i  me  rations,  and  various  skin  eruptions.  The  tropho-neuroses,  if 
they  affect  joints,  are  called  arthropathies;  if  muscles,  atrophies, 
hypertrophies,  and  dystrophies;  or  if  with  atrophy  there  is  a  great 
substitution  of  fat  the  condition  is  known  as  lipomatosis.  When 
nerves  are  affected  there  results  degeneration.  Tropho-neuroses  of 
the  skin  produce  various  symptoms,  such  as  herpes,  pemphigus,  and 
other  eruptions,  pigmentation,  leucoderma,  alopecia,  and  bedsores. 

5.  Vasomotor  and  Secretory  Symptoms. — The  nerves  supplying 
the  blood-vessels  and  secreting  glands  work  together  and  are  usually 
disordered  together.  Separate  disturbances  of  the  vessels  and 
glands,  however,  occur.  Angio-neurosis  is  the  term  given  to  dis- 
orders of  the  vasomotor  centre  and  nerves.  AngtO'spasm  is  a  con- 
dition in  which  there  is  increase  of  vasomotor  tone  and  spasmodic 
contraction  of  the  muscular  coats  of  the  arteries.  Angio-paralysis 
represents  the  opposite  condition.  Such  disorders  affecting  the  skin 
are  shown  by  pallor  and  coolness  or  by  flushing  and  heat.  Angw- 
ataxia  is  a  condition  of  variability  and  irregularity  in  the  tonus  of 
the  blood-vessels. 

(>.  The  secretory  neuroses  affect  the  functions  of  the  skin,  mucous 
membranes,  and  special  glands.  Hyperidrosis  is  an  excessive  sweat- 
ing.    Anidrosis  is  excessive  dryness.     Paridrosis  is  a  perversioD 


38  DISEASES  OF  THE   NEKVOUS   SYSTEM. 

of  secretion  in  which  peculiar  odors  or  colors  are  noted.  Hcemi- 
drosis  is  the  term  applied  to  bloody  sweating. 

The  secretions  of  the  internal  organs  are  controlled  by  nervous 
influences,  and  their  special  disturbances  often  form  part  of  the 
symptoms  of  nervous  diseases.  Thus  we  have  watery  diarrhoea  in 
Basedow's  disease,  and  a  peculiar  membranous  discharge  from  the 
boAvel  in  asthenic  states. 

The  blood  glands,  and  particularly  the  thyroid  and  pituitary 
gland,  have  perversions  of  function  which  lead  to  serious  nervous 
symptoms,  which  will  be  described  under  the  head  of  exophthalmic 
goitre  and  acromegaly. 


CHAPTER  V. 

DIAGNOSIS  AND   METHODS   OF  EXAMINATION. 

The  diagnosis  of  a  nervous  disease  may  be  simply  a  clinical  one  ; 
that  is  to  say,  one  may  recognize  it  as  belonging  to  a  certain  known 
and  definite  group  of  symptoms.  Thus  in  recognizing  the  phenom- 
ena of  epilepsy,  one  makes  a  clinical  diagnosis.  In  other  cases,  and 
especially  in  all  organic  nervous  diseases,  the  physician  must  make 
in  addition  a  local,  and  then  a  pathological  diagnosis.  That  is,  we 
must  determine  the  seat  and  nature  of  the  disease. 

A  diagnosis  is  made  by  first  getting  all  the  obtainable  facts  in 
the  patient's  past  history,  then  by  learning  from  him  all  his  subjec- 
tive symptoms,  and  finally  by  making  an  examination  according  to 
the  technical  methods  to  be  here  described.  In  examining  a  patient, 
it  is  imperative  that  a  careful  search  for  diseases  outside  the  nervous 
system  first  be  undertaken.  Then  the  morbid  nervous  phenomena 
should  be  investigated.  The  physician  should  make  it  an  invariable 
rule  to  make  this  examination  in  a  certain  fixed  and  systematic 
manner.  The  best  method  is  first  to  get  the  family  and  personal 
history,  and  then  to  go  over  the  mental,  cerebral,  and  special  ner- 
vous functions  serially  in  the  way  indicated  under  the  description 
of  general  symptoms,  thus :  Examine — 

1.  Physiognomy,  general  condition  of  nutrition,  complexion, 
physical  defects  (stigmata  of  degeneration),  gait,  station,  posture, 
speech. 

2.  Mental  and  cerebral  symptoms. 

3.  Motor  and  muscular  symptoms,  including  muscular  and  joint 
atrophies,  electrical  reactions,  and  the  reflexes. 

4.  Sensory  symptoms,  general  and  special. 

5.  Vasomotor,  trophic,  and  secretory. 

6.  Visceral  centres. 

In  investigating  the  family  history,  it  is  often  necessary  to  make 
very  direct  and  probing  inquiries,  for  patients  are,  as  a  rule,  inclined 
to  forget  or  ignore  the  existence  of  nervous  and  mental  disease 
among  relatives.  The  existence  of  consumption  and  inebriety,  epi- 
lepsy and  syphilis,  in  the  direct  line  arc  very  important  facts;  so 
also  are  those  concerning  birth.  The  patient  should  be  questioned 
closely  as  to  his  previous  diseases,  especially  syphilis;  alsoastohia 


40  DISEASES    OF   THE    NERVOUS    SYSTEM. 

habits  in  relation  to  sexual  indulgence,  indulgence  in  alcohol,  and 
smoking.  In  women,  the  tea  habit  should  be  inquired  into.  The 
patient  may  be  allowed  to  tell  his  own  story  first.  Proper  queries 
should  be  put  to  supplement  this,  and  finally  the  patient  should  be 
asked  to  state  those  symptoms  which  to  his  mind  are  main  and 
dominant. 

We  will  now  go  over  the  above  points  in  detail. 

1.  The  physiognomy,  complexion,  and  general  nutrition  are  first 
noted.  Many  nervous  disorders  are  compatible  with  a  very  healthy 
appearance,  and  patients  often  make  the  introductory  apology,  "  I 
don't  look  like  a  sick  person."  An  anxious  look,  restless  manner, 
and  excited  or  diffident  speech,  however,  often  show  something 
wrong.  The  nervous  trouble  is  usually  serious  in  reverse  proportion 
to  the  voluble  anxiety  of  the  patient  to  make  his  condition  exactly 
understood.  The  character  of  the  gait  may  reveal  at  once  the 
nature  of  the  malady.  The  dropped  foot  and  flaccid  swing  of  the 
leg  in  poliomyelitis  and  neuritis,  the  stiff  shuffling  march  of  para- 
plegia from  myelitis,  the  waddling  movements  of  juvenile  muscular 
dystrophy,  and  the  bent  head  and  careful  stamp  of  locomotor  ataxia 
are  almost  of  themselves  diagnostic : 

J£t  cents  incessu  jjutuit  morbus. 

The  speech  also  often  betrays  the  malady.  The  physician  soon 
gets  to  recognize  not  only  the  striking  symptoms  of  aphasia,  but  also 
the  weak  piping  of  paralysis  agitans,  the  stumbling  enunciation  of 
paresis,  and  the  peculiar  dysarthrias  of  multiple  sclerosis  and  bul- 
bar palsy.  As  a  rule,  the  occurrence  of  speech  difficulties  in  adults 
is  significant  of  organic  and  often  serious  disease. 

I  regard  it  of  much  importance  that  in  the  chronic  and  constitu- 
tional nervous  maladies  careful  note  be  made  of  the  marks  of  degen- 
eration. The  nature  of  this  condition  has  already  been  described 
under  the  head  of  hereditary  causes  of  nervous  disease.  As  already 
stated,  degeneration  means  a  marked  and  morbid  deviation  from  the 
normal  standard  of  the  race.  The  existence  of  degeneration  implies 
an  imperfect  or  an  unbalanced  development  of  the  body.  The  con- 
dition is  usually  sIioavu  in  some  nervous  or  mental  defect  in  the 
individual,  and  degeneracy,  as  ordinarily  understood,  implies  a  neu- 
ropathic or  psychopathic  state.  But  degeneracy  may  also  mean  only 
a  lessened  vital  resistance  to  certain  forms  of  infection  or  injury, 
as,  for  example,  in  persons  of  a  tuberculous  tendency,  who  often 
have  marks  of  degeneracy.  However,  in  ordinary  use  of  the  term  it 
applies  to  those  who  have  inherited  nervous  and  mental  weaknesses. 
The  degenerate  shows  certain  marks  which  are  called  the  stig- 
mata  of   degeneration.      These    are  of   three  kinds:    anatonii<;d, 


DIAGNOSIS    AXD    METHODS    OF    EXAMINATION".  41 

physiological,  and    mental.      I    have    space  to    give  only  the  more 
important. 

Anatomical  stigmata  : 

Cranial  anomalies,  e.g. 
Asymmetry  of  cranium. 
Microcephalus. 
Peculiar  shape  of  skull,  trigonal,  scapho-cephalic,  plagio- 

cephalic. 
Facial  asymmetry,  and  excessive  prognathism. 
Large  jaws. 
Deformities  of  the  palate  and  uvula,  including  high  narrow 

arch  and  the  torus  palatinus. 
Anomalies  of  the  teeth,  tongue,  and  lips. 
Anomalies  of  the  eyes :  narrow  palpebral  fissure,  muscular 

insufficiency,  excessive  astigmatism,  nystagmus. 
Anomalies  of  the  ears:    badly  placed,  ugly  shapes,  asym- 
metry, adherent  or  lobeless  ears,  markedly  conchoidal 
ears. 
Anomalies  of  the  limbs,  genital  organs,  and  body  generally. 
Anomalies  of  the  skin,  excessive  hairiness,  or  absence  of 
hair. 
Physiological  Stigmata. — Tremor,  tics,  nystagmus,   and  hered- 
itary defects  in  the  muscular  system  leading  to  atrophies.     Exces- 
sive or  defective  sensibility  of  the  cutaneous  and  special  senses, 
defects  in  speech,  perversions  of  the  sexual  and  other  instincts  are 
to  be  classed  here.     A  diminished  resistance  to  nervous  and  emo- 
tional strain  is  a  most  frequent  physiological  mark  of  degeneracy. 

Mental  Stigmata. — These  include  all  those  factors  that  make  up 
the  erratic,  unbalanced,  and  morbidly  emotional  individual.  The 
specially  morbid  note  in  these  persons,  as  Peterson  says,  is  an  ex- 
cessive egotism,  an  intense  self -consciousness,  often  with  peculiar 
disturbances  of  the  sense  of  personality.  Mental  degeneracy  is 
often  associated  with  great  special  aptitudes,  even  genius,  and  is 
quite  compatible  with  sanity  and  a  fair  degree  of  health. 

Of  the  foregoing  the  most  important  of  the  anatomical  stigmata 
are  deviations  in  the  symmetry  and  shape  of  the  skull,  defects  in 
the  palate  and  under  jaws,  badly  shaped  ears,  badly  set  teeth, 
and  a  generally  weak  and  badly  developed  body.  Stress  is  laid 
upon  the  skull  because  its  development  corresponds  with  that  of  the 
brain.  The  palatal  stigmata  are  in  general  those  which  make  the 
cavity  of  the  mouth  smaller,  it  being  the  fact  that  the  mouth  cavity 
increases  in  size  as  Ave  ascend  the  vertebrate  series  (Peterson).  Ab- 
normal palates  are  found  in  about  ten  pes  cent,  of  normal  people 
(Charon)  and  in  from  forty-six  to  eighty  per  cent,  of  degenerates. 
The  high  narrow  palate  is  one  oftenest  seen  by  myself.  The  torus 
palatinus  or  longitudinal  ridge  on  the  hard  palate  is  significant  if  it 


42 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


is  well  marked.  The  importance  of  defective  ears  is  based  upon 
comparative  observations.  They  are  found  in  from  twenty  to  sixty- 
four  per  cent,  of  degenerate  persons. 

While  many  of  the  stigmata  have  no  significance  in  themselves, 
yet  a  combination  such  as  impresses  the  observer  with  its  prepon- 
derance is  of  great  importance,  for  neuroses  or  psychoses  developed 
among  this  class  have  a  much  more  unfavorable  prognosis.  It  is 
especially  among  neurasthenics,  epileptics,  severe  forms  of  hysteria, 
and  in  the  insanities  that  these  signs  are  to  be  looked  for  and  stud- 
ied. Among  normal  men  about  two  or  three  anatomical  stigmata 
are  often  found  5  among  lunatics,  criminals,  abortive  types  of  para- 
noia, and  primary  forms  of  neurasthenia,  the  number  is  much  greater. 

The  accompanying  table  will  be  of  help  in  making  the  investiga- 
tions relating  to  the  cranium  (page  43) . 

To  understand  it,  it  is  necessary  to  describe  the  skull  landmarks, 
and  to  give  briefly  the  classification  and  terms  used  by  anthropolo- 
gists and  alienists  in  describing  the  dimensions  and  shape  of  the  skull. 

Dimensions  and  Shape  of  Skull  —  General  Classification. — 
Anthropologists  make  a  general  classification  of  skulls  into : 


Fig.  19.  —  M,  j3,  T,  The  Triangle  for  Ascertaining  the  Empirical  Greatest  Height 

(Benedict). 

The  dolichocephalic,  in  which  the  antero-posterior  diameter  is 
to  the  transverse  as  100  is  to  75  or  less;  the  brachycephalic,  in 
which  the  length  is  to  the  breadth  as  100  is  to  80  or  more;  the 
mesocephalic,  in  which  the  length  is  to  the  breadth  as  100  is  to  75 
to  80.  The  physiological  limits  of  variation  in  the  ratio  of  length 
to  breadth  are  from  100  to  70  to  100  to  90.  The  dimensions  and 
shape  of  the  skull  vary  with  age,  sex,  individual,  race,  and  with 
certain  pathological  conditions  and  artificial  deformities.  In  gen- 
eral, however,  the  variations  in  the  shape  and  size  of  the  skulls  of 


DIAGNOSIS    AND    METHODS    OF    EXAMINATION. 


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44  DISEASES   OF   THE   NERVOUS   SYSTEM. 

healthy  adults  of  European  and  American  races  are  fairly  uni- 
form. 

Variations  Dependent  upon  Age. — The  proportions  of  the  skull 
change  most  considerably  in  the  first  year,  and  continue  to  change 
up  to  the  fourth  year.  After  that,  modifications  are  slight  in 
amount  and  appear  more  slowly.  By  the  end  of  the  seventh  year 
the  skull  has  nearly  reached  its  full  size  (see  table),  more  nearly  in 
girls  than  in  boys.  The  chief  measurements  during  childhood  are 
given  in  the  table.  The  protuberances  and  ridges  are  less  marked 
in  children. 

The  female  slut  11  is  larger  posteriorly,  is  broader,  lower,  with 
higher  orbital  diameter;  often  it  has  no  glabella,  no  super-glabellar 
depression,  and  is  less  well  marked  as  to  its  ridges,  prominences, 
and  sutures. 

Variations  as  Regards  Race. — The  length-breadth  index  and 
other  cranial  indices  and  the  volume  are  the  only  racial  differences 
so  far  extensively  studied.  Even  these  are  too  indefinite  factors  to 
be  of  any  practical  value.  In  general,  we  may  say  that  the  doli- 
chocephalic or  long-headed  are :  the  English,  Irish,  Scandinavians, 
negroes,  73;  Arabs,  74;  Chinese,  76.  The  brachy cephalic  or  broad- 
headed  are:  the  Germans,  81;  Russians,  Turks,  81.  The  meso- 
cephalic  or  medium-shaped  heads  are:  the  American  Indians,  79; 
Hollanders,  Parisians,  79. 

The  Variations  Dependent  upon  Artificial  Deformities,  Accidents, 
Perversions  ,,f  Growth  and,  Development,  ami  upon  Disease. — There 
are  certain  more  or  less  pathological  variations  in  the  shape  of  the 
skull,  due  to  a  premature  ossification  of  a  suture,  or  arrest  of  devel- 
opment in  a  centre  of  ossification,  or  to  a  hyperplasia  or  aplasia  of 
a  part  of  the  skull  or  of  its  contents.  When  one  part  is  shut  off 
from  its  natural  expansion,  other  parts,  as  a  rule,  undergo  compen- 
satory development.  This  principle  underlies  the  pathology  of  cra- 
nial deformities.  Those  deformities  which  it  would  be  well  to  look 
for  are : 

The  triangular  or  trigono-cephalic  skull;  the  keel-shaped  or 
scapho-cephalic  skull;  the  acrocephalic  or  pointed  skull;  the  oxy- 
cephalic or  steeple-shaped  skull ;  the  flat-headed  skull ;  the  plagio- 
cephalic  or  obliquely  deformed  skull. 

Variations  in,  the  Neuropathic 'and  Psychopathic  Classes. — -Varia- 
tion from  the  regular  type  is  oftener  found  in  these  classes  than  in 
the  normal,  but  definite  variations  corresponding  with  a  special  type 
of  disease  are  not  yet  made  out. 

For  all  ordinary  purposes  the  only  instruments  needed  in  exam- 
ining the  cranium  are  a  tape,  a  strip  of  lead  to  use  as  a  conforma- 
tor,  and  a  pelvimeter. 

2.  Investigation  of  Svmptoms  of  Disordered  Motility. — 
In  studying  the  attitude,  expression,  gait,  and  speech,  some  notion 
of  the  condition  of  the  motor  functions  has  been  obtained.      Special 


DIAGNOSIS   AND    METHODS    OF    EXAMINATION. 


45 


disturbances  of  the  various  parts  must  then  be  investigated.  The 
patient  is  made  to  extend  the  arms  and  move  them  in  all  possible 
ways;  the  face,  trunk,  and  lower  limbs  are  put  through  all  their 
changes.  The  degree  of  paralysis  in  some  groups  of  muscles  can 
be  measured  by  dynamometers.  The  ordinary  hand  dynamometer 
of  Mathieu  measures  the  degree  of  paralysis  in  the  flexors.  Tt 
should  be  graduated  accurately  in  pounds  or  kilograms. 

The  average  power  of  pressure  on  the  Mathieu  dynamometer  is, 
for  an  adult,  forty  to  fifty  kilograms  for  the  right  band,  and  three 
to  five  kilograms  less  for  the  left.  A  woman  bas  about  two-thirds 
of  the  power  of  a  man.  I  have  bad  constructed  an  apparatus  by 
which  the  strength  of  the  leg  push,  i.e.,  of  the  ex- 
tensors of  the  leg  and  foot,  and  the  extensors  of  the 
thigh  is  tested.  Dr.  W.  Kraus  has  devised  a 
simpler  instrument.  The  anterior  tibial  and  calf 
muscles  can  also  be  tested  by  means  of  an  instru- 
ment called  the  pedodynamometer  devised 
by   the   late   Dr.   William   E.    Birdsall. 


f 


■m 


Fig.  23.— Leg  Dynamometer. 


Fir;.  24.— Foot  Dynamometer. 


A  good  idea  of  the  degree  of  paralysis  can  be  got  by  making  the 
patient  take  the  physician's  two  hands  with  his  own  and  squeeze 
each  at  the  same  time.  A  malingerer  or  hysteric  will  often  in  this 
way  unconsciously  press  much  harder  than  he  is  aware.  Th  phy- 
sician's own  ingenuity  will  suggest  various  ways  of  testing  the 
strength  of  the  leg  and  thigh  muscles,  such  as  making  the  patient 
rise  on  one  toe,  climb  upon  a  chair,  push  against  an  object  with  his 
foot,  etc. 

Tremor  is  tested  by  making  the  patient  hold  out  the  hands  and 
arms  at  full  length,  spreading  out  the  fingers  at  the  same  time.  To 
determine  whether  the  tremor  increases  on  volitional  movement, 
give  the  patient  a  full  glass  of  water,  let  him  hold  it  out  for  a  mo- 
ment, then  bring  it  to  his  mouth  slowly.  If  the  tremor  incn 
with  this  movement  it  is  called' "intention."  La  a  general  rule. 
the  tremor  of  organic  disease  is  increased  by  volitional  movement, 


46  DISEASES    OF   THE   NERVOUS   SYSTEM. 

and  ceases  during  rest  of  the  extremity.  Functional  tremors  are 
usually  continuous.  In  most  forms  of  tremor  the  hand  and  arm 
shake  as  a  whole.  In  other  forms  the  tremor  involves  only  the 
fingers  or  hand  or  forearm  and  hand.  Such  tremor  is  called  seg- 
mental.    It  is  especially  seen  in  paralysis  agitans.     As  I  have  already 


S=10VD 


Fig.  25.— Diagram  of  a  Fine  Vibratory  Tremor.    Ten  of  the  divisions  on  the  lower  line 

equal  a  second. 

said,  tremor  may  be  fine  or  coarse,  i.e.,  four  to  six  or  eight  to  twelve 
per  second.  To  determine  this  accurately  a  special  apparatus  is 
needed ;  but  one  can  with  a  little  experience  determine  this  fairly 
well  by  observation  alone.  Or  we  can  use  a  sphygmograph,  as  shown 
by  Dr.  F.  Peterson.  This  instrument  is  fixed  firmly  on  the  table, 
and  the  tremulous  forefinger  held  lightly  against  the  lever.  Coarse 
tremor  is  usually  a  sign  of  organic  disease  or  of  paralysis  agitans, 
but  it  occurs  also  in  hysteria  and  grave  conditions  of  alcoholism. 
Tremor  that  is  hardly  observable  by  the  eye  can  be  felt  by  placing 
one's  hand  against  the  extended  fingers  of  the  patient.  Tremor  of 
the  tongue  and  lips  and  facial  muscles  must  be  carefully  looked  for. 
It  is  tested  by  making  the  patient  close  the  eyes  tightly  and  show 
the  teeth  or  protrude  the  tongue.  Facial  tremor  if  very  marked 
usually  indicates  a  serious  condition  of  nervous  exhaustion,  alco- 
holic poison,  or  perhaps  oftenest  of  paresis.  Tremor  of  the  whole 
head  due  to  the  neck  muscles  must  be  distinguished  from  secondary 
shaking  of  the  head  due  to  a  tremor  of  the  trunk. 

Fibrillary  tremor,  which  involves  only  certain  fibres  of  the  mus- 
cle, is  seen  oftenest  in  the  tongue  and  face  and  muscles  of  the 
extremities.     It  indicates  wasting  or  exhausted  muscles. 

Choreic  movements,  tics,  associated  and  forced  movements,  and 
the  other  forms  of  motor  disturbance  can  be  recognized  by  simple 
observation. 

Myoidema  is  a  tonic  spasm  of  a  part  of  a  muscle  near  its  tendon- 
ous  attachment.  It  is  produced  by  a  sharp  blow  upon  the  muscle 
near  its  tendonous  insertion.  This  causes  the  muscular  fibres  to 
bunch  up  into  a  small  tumor  for  several  seconds.  Its  presence 
indicates  rapid  muscular  wasting  from  exhausting  disease. 

Idiopathic  muscular  spasm  is  a  phenomenon  of  a  similar  nature. 
When  the  belly  of  a  muscle  is  struck  with  a  dull  instrument,  a 


DIAGNOSIS   AND    METHODS   OF   EXAMINATION".  47 

welt  of  contracted  muscle  appears  and  lasts  several  seconds.  It 
indicates  an  exaggerated  muscular  irritability. 

The  Examination  of  the  Reflexes. — These,  as  already  stated, 
are  of  four  kinds :  (1)  the  superficial  or  skin,  (2)  the  deep  or  ten- 
donous,  (3)  the  visceral,  and  (4)  the  muscle  reflexes. 

1.  A  skin  or  superficial  reflex  is  produced  by  scratching,  tick- 
ling, pinching,  or  irritating  the  skin  with  hot,  cold,  or  chemical 
irritants.  The  result  is  a  contraction  of  the  muscles  supplying  the 
parts  near  the  irritation.  The  skin  reflexes  which  can  be  ordinarily 
brought  out  are  the  plantar,  cremasteric,  epigastric,  abdominal,  erec- 
tor spinal,  interscapular,  palmar,  scapulo-humeral,  and  certain  cra- 
nial reflexes. 

The  plantar  reflex  is  produced  by  tickling  or  scratching  the  soles 
of  the  feet.  This  causes  usually,  when  carefully  done,  a  slight  flex- 
ion of  the  toes.  In  many  cases  there  is,  however,  no  response. 
In  irritable  persons  and  children  there  is  a  sudden  dorsal  flexion  of 
the  foot,  and  often  a  contraction  of  the  inner  hamstring  muscles. 
In  pathological  conditions  involving  the  pyramidal  tracts  of  the 
cord  or  even  the  motor  centres  and  tracts  in  the  brain  there  is  a 
dorsal  flexion  of  the  toe.  This  is  called  the  Hexor  resjjonse  or  the 
sign  of  Babiaski. 

The  cremasteric  reflex  is  brought  out  by  scratching  the  inner 
side  of  the  thigh  or  the  skin  over  Scarpa's  triangle.  It  causes  a 
drawing  up  of  the  testicle,  not  of  the  scrotum  alone,  on  the  same 
side. 

The  abdominal  reflex  consists  of  a  contraction  of  the  abdominal 
recti  muscles,  caused  by  irritating  the  side  of  the  abdomen. 

The  epigastric  reflex  consists  of  a  contraction  of  the  upper  fibres 
of  the  rectus,  caused  by  irritating  the  skin  of  the  lower  part  and 
side  of  the  thorax. 

The  erector-spinal  reflex  consists  of  a  contraction  of  some  of  the 
fibres  of  the  erector  spinae,  caused  by  irritating  the  skin  along  its 
outer  edge. 

The  scapular  reflex  consists  of  a  contraction  of  some  of  the  scap- 
ular muscles,  caused  by  irritating  the  skin  over  them. 

The  palmar  reflex  is  produced  by  irritating  the  palms  of  the 
hands. 

The  cranial  reflexes  are  the  lid  reflex,  caused  by  irritations  of 
the  conjunctiva  or  of  the  retina;  the  pupillary-skin  reflex,  which 
consists  of  a  dilatation  of  the  pupil  caused  by  scraching  the  skin  of 
the  cheek  or  chin. 

The  palmar  reflex  is  rarely  present  in  healthy  people  except 
during  sleep,  and  in  children.  The  superficial  reflexes  depend  upon 
the  integrity  of  the  reflex  spinal  arc,  and  to  a  less  extent  upon  the 


48 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


degree  of  cerebral  inhibition.  When  present,  they  show  that  the 
spinal  cord  at  the  level  through  which  the  impulses  travel  is  healthy. 
"When  absent,  they  do  not  necessarily  indicate  much  of  anything, 
for  they  vary  in  amount  in  different  persons  and  at  different  ages. 
In  cerebral  hemiplegia  during  and  for  a  time  after  the  acute  attack, 
they  are  generally  lessened  or  absent  on  the  affected  side.  Later 
they  may  be  exaggerated. 

The  levels  of  the  spinal  cord  through  which  the  impulse  travels 
are  indicated  in  the  accompanying  table : 


Spinal 
Nerve. 


3 

4 
5] 


Dpepaud  Super- 
ficial Reflex. 


Spinal 
Nerve. 


10 


c 


1. 

o 
3 

H 

q<3  I 


12 


Deep  and  Super- 
ficial Reflex. 


Abdominal 


}»  Elbow  jerk 


J 


Scapular 


J 

11 


3J 


Knee  jerk 


Cremasteric 


Epigastric 


s 
I    4 

H 
5 

1 

2 

3 

§    4 


I  An 


Gluteal 
klejerk  and  clonus 


Plantar 


7J 


Spinal  Cord  Levels  of  the  Superficial  and  Deep  Keflexes. 

The  deep  reflexes  are  sometimes  called  tendon  reflexes,  though 
this  is  not  a  strictly  correct  name,  since  they  can  be  called  out  by 
striking  periosteum  or  muscle  as  well  as  tendons.  The  deep  reflex 
in  all  these  cases  is  probably  a  true  spinal  reflex,  though  some  assert 
that  it  is  due  to  the  direct  effect  of  the  concussion  or  sudden  stretch- 
ing upon  the  muscle  itself  (Growers),  which  is  in  a  condition  of 
slight  tonus.  Those  who  accept  this  view  speak  of  the  deep  reflex 
as  indicating  the  myotatic  irritability  or  muscular  tonus.  Either 
view  involves  the  integrity  of  a  reflex  arc. 

The  deep  reflexes  are  very  numerous.     The  important  are : 
The  patella-tendon  reflex  or  knee  jerk.     The  ankle  reflex  or 


DIAGNOSIS    AND    METHODS    OF    EXAMINATION. 


49 


ankle  clonus.  The  wrist  reflex.  The  triceps-tendon  reflex  or  elbow 
jerk  The  jaw  reflex  or  chin  jerk.  The  light  (or  pupillary)  and 
accommodation  Cor  ciliary )  reflexes. 

The  patella  reflex  or  knee  jerk  consists  of  a  sudden  contraction 
of  the  quadriceps  femoris,  vastus  internus,  and  subcrureus  caused 
by  striking  the  patella  tendon  when  the  leg  hangs  loosely  at  right 


Fig.  20.— Getting  the  Knee  Jerk  BY  He-enforcement. 


50 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


angles  with  the  thigh.  This  reflex  may  also  often  be  produced  by- 
striking  the  lower  part  of  the  muscle  itself.  The  activity  of  this 
reflex  is  increased  if,  at  the  same  time  that  the  blow  is  struck,  a 
voluntary  contraction  of  some  other  muscles  is  made  by  the  patient. 
Usually  the  patient  is  told  to  pull  on  his  clasped  fingers,  or  tightly 
shut  the  hands.  This  process  is  called  the  re- enforcement  of  the 
knee  jerk  (see  Fig.  26).  Such  re-enforcement  can  be  caused  by 
irritating  the  skin  and  by  various  sensory  or  psychic  stimuli.  The 
nerve  roots  involved  are  those,  in  man,  of  the  second  and  third  lum- 
bar segments.  The  peripheral  nerve  is  the  anterior  crural.  The 
most  essential  muscles  are  the.  vastus  iuternus   (Sherrington)  and 


Fig.  2~. — Getting  the  Elbow  Jerk. 

the  quadriceps.  The  wrist  reflex  is  brought  out  by  striking  the 
Avrist  tendons  while  the  forearm  is  supinatecl  and  held  limply  on  the 
hand  of  the  physician.  The  triceps  reflex  or  elbow  jerk  is  brought 
out  by  striking  the  triceps  tendon  while  the  arm  is  supported  and 
the  forearm  allowed  to  hang  down  loosely  at  right  angles  to  the  arm 
(Fig.  27).  These  reflexes  occur  in  normal  individuals.  The  jaw 
reflex  or  jaw  jerk  is  brought  out  by  having  the  patient  open  the 
mouth  and  leave  the  jaw  relaxed.     A  flat  instrument  like  a  paper 


DIAGNOSIS    AND    METHODS    OF    EXAMINATION. 


51 


cutter  is  then  laid  on  the  teeth  of  the  lower  jaw,  and  if  this  is  struck 
smartly  the  elevators  of  the  jaw  contract.  The  light  reflex  is  caused 
by  throwing  a  bright  light  into  the  eye,  and  the  ciliary  or  accommo- 
dation reflex  by  making  the  patient  look  at  a  distant  and  then  at  a 
near  object.  The  pupil  normally  dilates  in  the  former  case  and  con- 
tracts in  the  latter.  When  the  light  reflex  is  lost  while  the  accom- 
modation reflex  remains,  the  condition  is  called  the  Argyll- Robertson 
pupil. 

Ankle  clonus  is  caused  by  having  the  seated  patient  extend  the 
limb  and  hold  it  rather  firmly  in  a  semiflexed  condition.  The 
physician  takes  the  foot  by  the  toe  and  heel  and  quickly  flexes  the 
foot  on  the  leg.  He  thus  suddenly  stretches  the  calf  muscles,  and 
they  undergo  rhythmical  contraction.  This 
phenomenon  does  not  occur  in  healthy  peo- 
ple. It  is  found  in  transverse  and  compres- 
sion myelitis  and  in  degeneration  of  the 
lateral  columns  of  the  cord,  and  it  usually  in- 
dicates organic  disease  of  the  cord.  A  pseu- 
do-clonus   sometimes  occurs  in  which  there 


fit;.  28.— Getting  Ankle  ('mints. 


are  a  few  rhythmical  contractions  on  sudden  dorsal  flexion  of  the 
foot,  but  the  contractions  soon  subside.  This  is  seen  in  neurasthenia 
and  hysteria. 

The  deep  reflexes,  and  in  particular  the  knee  jerk,  for  that  is  the 
one  most  easily  and  often  tested,  are  practically  always  present  in 
health.  They  may  be  decreased,  delayed,  absent,  or  exaggerated. 
Their  exaggeration  is  common  and  not  of  special  clinical  signifi- 
cance. The  absence  of  the  knee  jerk  is  of  great  significance,  indi- 
cating in  persons  who  have  no  paralysis  of  the  crural  muscles, 
locomotor  ataxia,  neuritis,  or  some  toxaemia,  such  as  follows  diph- 
theria or  exists  in  diabetes. 

The  "paradoxical  contraction"  is  a  name  given  to  the  tonic  con- 


52  DISEASES    OF   THE    NERVOUS    SYSTEM. 

traction  of  the  anterior  tibial  muscles  caused  by  the  physician's 
suddenly  flexing  the  foot  on  the  leg,  thus  shortening  these  muscles. 
This  is  a  rare  phenomenon,  never  found  in  health,  and  usually  as- 
sociated with  excessive  spasticity  of  the  legs. 

The  Eleefrietd  Conditions  in  Disturbances  of  Motility.  —  These 
cannot  be  understood  without  some  description  of  the  methods  of 
using  electricity,  and  hence  the  technique  of  electrical  examinations 
for  purposes  of  diagnosis  will  be  described  under  the  head  of  treat- 
ment. 

Examixatiost  of  the  Disordebs  of  Sensation. — The  object 
of  examining  the  sensory  functions  is  to  see  if  they  are  exaggerated, 
perverted,  or  lost,  and  to  locate  the  extent  of  the  disturbance. 
Patients  differ  greatly  in  their  intelligence  and  power  of  description, 
so  that  great  care  must  be  taken  in  drawing  conclusions  as  to  sen- 
sory disturbances.  In  examining  the  skin  and  muscle  senses,  the 
patient's  eyes  should  be  closed  and  he  should  be  carefully  told  to 
answer  promptly  whenever  he  feels  the  stimulus.     It  is  best  to  in- 


Fio.  29, — Instrument  for  Testing  Tendon  Reflexes. 

sist  that  he  always  reply  in  the  same  way,  e.g.,  using  the  word 
"  now"  the  moment  the  sensation  is  felt.  Many  ingenious  instru- 
ments have  been  devised,  and  I  have  described  some  of  them,  but 
for  ordinary  purposes  a  camel' s-hair  pencil  and  a  pin  answer  very 
well. 

Sensations  are  of  two  kinds,  general  or  common  and  special.  A 
common  sensation  is  one  which  is  referred  to  the  body,  and  it  is 
subjective  in  character.  A  special  sensation  is  one  which  is  referred 
to  the  external  world,  and  in  particular  to  the  object  which  causes 
the  stimulus.  The  pain  from  a  knife  cut  is  referred  to  the  body, 
and  is  a  common  sensation.  The  coldness  felt  when  a  knife  blade 
is  laid  on  the  skin  is  referred  to  the  knife,  and  is  a  special  sensation. 
Special  senses  give  us  very  often  objective  symptoms,  i.e.,  such  as 
can  be  noted  directly  by  the  physician. 

The  sensory  functions  to  be  examined  are : 

The  cutaneous. 

The  muscular,  ai'ticular,  and  tendonous. 

The  visual,  auditory,  olfactory,  gustatory,  and  space  senses. 

Visceral  and  general  bodily  sensations. 


DIAGNOSIS   AND    METHODS    OP    EXAMINATION. 


53 


The  cutaneous  sensations  are:  (1)  The  tactile  sense,  which  in- 
cludes pressure  and  contact ;  (2)  the  temperature  sense,  which  in- 
cludes the  heat  sense  and  cold  sense;  (3)  the  jjain  sense.  The  first 
two  are  special  senses,  the  last  is  a  general  sense.* 

To  test  the  tactile  sense,  blindfold  the  patient  and  use  the  aesthe- 
siometer.  This  is  an  instrument  with  two  rather  blunt  points, 
which  can  be  separated  or  approximated.  A  hairpin  or  two  ordi- 
nary pins  can  be  used  in  its  stead.  Its  use  depends  upon  the  fact 
that  the  power  to  appreciate  the  contact  of  two  points  on  the  skin 
gradually  approximated  varies  with  the  tactile  sensibility  of  the 
patient.  The  tongue,  finger  tips,  and  lips  are  the  most  sensitive 
points.     The  back,  arms,  and  thighs  the  least  sensitive. 

The  following  table  shows  the  average  distance  at  which  two 
points  are  appreciated  as  such  by  an  intelligent  adult: 

Tip  of  tongue 1mm.  (g^in. ).     Tip  of  toes,  cheeks,  eyelids  . .   12  mm. 


Tip  of  fingers 2 

Lips 3 

Dorsal      surface      of 

fingers 6 

Tip  of  nose 8 

Forearm 9 


Temple 13 

Back  of  hands 30 

Neck 35 

Forearm,  leg,  back  of  foot..  40 

Back GO-80 

Arm  and  thigh 80 


The  figures  vary  somewhat  with  the  thickness  or  softness  of  the 
skin  and  with  the  dulness  or  keenness  of  the  nervous  organization. 
If  tin;  distances  are  double  those  given  above,  it  may  be  considered 
in  most  cases  abnormal,  f 

The  sense  of  contact,  which  is  a  form  of  tactile  sense,  is  tested 
by  drawing  a  pencil  or  a  bit  of  cotton  lightly  over  the  skin.  The 
sense  of  locality  or  power  to  localize  a  point  on  the  skin  that  has 
been  touched  varies  with  the  tactile  sense  and  with  the  muscular 
sense.     It  is  tested  by  placing  the  finger  lightly  on  a  given  spot  and 


*  Psychologists  deny  the  independence  of  the  pain  sense,  and  assert  that  it 
is  only  a  quality  or  modification  of  other  senses. 

f  The  tactile  sense  may  also  be  tested  by  the  writing-method  (Rumpf). 
Figures  or  letters  are  written  upon  the  skin  with  a  hard-pointed  instrument, 
and  the  patient  is  asked  to  tell  them.  The  figures  drawn  are  made  larger  or 
smaller  in  accordance  with  the  decrease  or  increase  of  sensibility.  The  fol- 
lowing table  shows  the  different  Sfzea  as  appreciated  On  the  normal  skin  : 

Finger  tips ft.6  cm.  (!  in.)  high 

Palm 1  "     ( i  in. ) 

Neck 1  " 

Cheeks 1 

Forehead   1  "         "  " 

Arm,  forearm,  and  back  of  hand 1.5  to  2.1  "     (}  to  i  in.)       " 

Scapula l.-j  to  2..",  '• 

Calf  and  sole 3  "     (1J  iu.)  " 


54 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


telling  the  patient  with  closed  eyes  to  place  his  finger  on  the  part 
touched.  He  should  come  within  five  centimetres  of  it.  In  slight 
degrees  of  anaesthesia  dependent  upon  disease  of  the  sensori-motor 
areas  of  the  cortex  of  the  brain  this  is  an  important  test.  Further 
tests  may  be  made  by  moving  points  along  the  skin  and  asking  the 
patient  to  indicate  the  direction  of  the  motion ;  or  by  laying  variously 
shaped  objects  on  the  skin  and  asking  the  pa- 
tient to  tell  their  shape  or  position. 

To  test  the  pressure  sense,  one  may  use  the 
barsesthesiometer,  an  instrument  made  with  a 
spring  scale  measuring  the  amount  of  pressure 
made.  A  simpler  way  is  to  have  the  patient 
rest  the  hands  on  a  table  and  then  try  and 
determine  the  weight  of  different  objects.  The 
lightest  weight  that  can  be  appreciated  on  the 
hands  or  face  is  one  of  about  0.02  gram  (gr.  £). 
Differences  of  light  weights  of  1  and  5  grams 
and  of  25  and  30  grams  are  about  all  that  can 
be  ordinarily  appreciated  by  the  skin.  Much 
smaller  differences,  of  0.5  to  2  grams,  can  be 
detected  if  great  care  is  used.  Weighted  rubber 
balls  may  be  used  in  the  foregoing  test.  I  pre- 
fer to  use  differently  weighted  metal  bodies, 
held  by  a  wire.  Pressure  sense  is  acute  on  the 
forearm  and  abdomen,  where  locality  sense  is 
feeble;  also  on  the  brow,  temples,  and  back  of 
the  hand.* 

Most  of  the  above  tests  are  not  ordinarily 
needed.  With  two  pins,  using  the  heads,  the 
presence  and  degree  of  anaesthesia  can  be  de- 
tected and  approximately  measured. 

The  temperature  sense  is  tested  by  test  tubes 
filled  with  hot  and  cold  water,  or  by  using  hot 
and   cold  spoons,  or  roughly  by  breathing  and 
then  blowing  on  the  part.     A  thermo-aesthesi- 
ometer  may  be  used.     This  has  a  round,  flat  sur- 
face one  centimetre  in  diameter,  and  contains  in 
its  terminals  thermometers  by  which  the  degree  and  differences  in 
temperature  may  be  noted  (Fig.  30).     A  small  heated  or  chilled 
surface  is  appreciated  much  less  easily  than  a  large  one. 

*  The  stereognostic  sense  is  one  dependent  on  the  use  of  the  tactile  and 
muscular  senses,  and  is  tested  by  placing  variously  shaped  objects  in  the  pa- 
tient's hands  and  asking  him  to  name  them. 


Fig.    30.  —  Combination 
jEsthesiometer. 


DIAGNOSIS    AND    METHODS   OF    EXAMINATION. 


5? 


The  indifferent  range  where  objects  are  felt  to  be  neither  warm  nor 
cold  is  from  27°  to  30°  C.  (80.6°  to  86°  F.).  Fine  differences  (0.2° 
to  1.5°  C.)  are  appreciated  above  the  indifferent  range.  Lower 
down  in  the  scale,  differences  from  1°  to  1.3°  C.  (2°  to  3°  F.)  are 
appreciable.  It  may  be  considered  a  morbid  symptom  if  temper- 
atures of  60°  to  65°  F.  are  not  felt  as  cold,  or  temperatures  of  86° 
to  95°  F.  are  not  felt  as  warm;  also  if  between  the  ranges  of  1°  C. 
(32°  F.)  and  40°  C.  (104°  F.)  differences  of  2°  C.  are  not  appre- 
ciated. A  painful  degree  of  sensitiveness  to  heat  or  cold  sometimes 
exists.  These  conditions  are  called  hyperthermalgesia  and  hyper- 
cy algesia  (Skinner,  Starr).  When  the  heat  or  cold  is  intense,  a 
sensation  of  pain  is  felt.  Cold  pain  is  produced  more  easily  in 
some  places,  such  as  the  elbow,  than  others,  as,  for  example,  the 
finger  tips.  Cold  pain  is  produced  by  temperatures  of  from  +2.8° 
C.  to  —11.4°  C.  Heat  pain  is  produced  by  temperatures  of  from 
36.3°  C.  to  52.6°  C. 

The  pain  sense  is  tested  by  pricking  the  skin  with  needles  or  the 
sharp  points  of  an  eesthesiometer.  The  faradic  battery  with  metal 
points  or  a  wire  brush  may  also  be  used.  Instruments  for  pinching 
the  skin  and  measuring  the  sensibility  by  the  strength  of  the  pinch 
have  been  devised.  The  power  of  localizing  pain  is  lessened  in  pro- 
portion to  the  analgesia. 

The  muscular  sensibility,  i.e.,  the  general  or  pain  sensation  of 
muscles,  is  tested  by  passing  the  faradic  current  through  the  part. 

Pain  and  temperature  sense  are  usually  affected  together. 

Delayed  Sensation. — The  time  taken  for  a  sensation  to  be  felt 
and  produce  a  voluntary  response  is,  for — 

A  touch  on  the  hand,  about 0. 12  second 

foot,       "      0.17       " 

Hearing 0. 13       " 

Sight 0.16       " 

Taste 0. 15 

The  tactile  sense,  as  well  as  the  other  special  and  the  general 
sensations,  may  show  a  delay  in  conduction.  The  tactile  sense 
especially  should  be  tested  on  this  point.  The  delay  may  amount 
to  several  seconds. 

"Double  Sensations   or  Polycesthesia. — When   the  touch  of   one' 
point  is  felt  as  two  or  more,  the  symptom  is  known  as  polyaesthesia. 
Referred  sensations  and  allochiria  are  described  under  Symptom- 
atology.    The  distribution  of  the  anaesthesia  must  be  determined. 
The  normal  nerve  supply  of  the  skin  is  shown  in  Figs.  31  and  32. 

Tests  for  the  Condition  of  the  Special  Sense  of  Muscles,  Joints, 
and  Tendons,  i.e.,  for  Ataxia. — Aiuesthesia  of  the  special  sensory 
nerves  of  the  muscles,  joints,  and  tendons  causes  ataxia  and  inco- 


56 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


ordination.  Muscle  anaesthesia  causes  chiefly  a  loss  of  weight  sense 
or  loss  of  power  to  determine  weights.  It  is  tested  by  the  use  of 
weights  suspended  by  a  string  so  as  to  exclude  pressure  sense ;  also 


Fig.  31.— Showing  the  Distribution  of  the  Sensory  Nerves  of  the  Skin. 


DIAGNOSIS   AND    METHODS    OF    EXAMINATION. 


57 


by  causing  the  patient  to  squeeze  a  dynamometer  up  to  a  certain 
fixed  number. 

In  articular  and  tendonous  anaesthesia  there  is  loss  of  posture 
sense.     It  is  tested  by  the  physician's  moving  the  patient's  limbs 


Fig.  32.— showing  thk  Distribution  op  the  Sensory  Nerves  of  tiik  skin. 


58 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


and  having  the  blindfolded  patient  tell  in  what  direction  the  move- 
ment is  made.  Or  he  is  told  to  follow  with  one  limb  the  move- 
ments which  the  examiner  makes  with  the  other. 

Muscular,  articular,  and  tendonous  anaesthesia  usually  exist  to- 
gether; there  is  then  ordinary  ataxia.  Such  ataxia  shows  itself 
in  standing  and  in  locomotion  and  other  voluntary  movements. 
Thus  we  have  a  static  ataxia  and  locomotor  or  motor  ataxia.  .Static 
ataxia,  or  inability  to  stand  (or  sit)  without  swaying  or  irregular 
movements,  is  tested  by  making  the  patient  stand  with  the  eyes 
closed  and  the  heels  and  toes  close  together.  Normally,  the  head 
moves  not  over  an  inch  in  this  position,  and  the  patient  holds  the 
head  and  body  more  rigid  with  the  eyes  closed  than  with  them 
opened.  In  ataxic  states  the  reverse  is  true,  and  decided  swaying 
or  even  complete  loss  of  equilibrium  occurs  with  the  eyes  closed,  or 
even  with  the  eyes  open,  and  the  base  narrowed 
by  putting  the  feet  together.  This  phenomenon 
is  called  the  " Brauch-Komberg  symptom."  In 
static  ataxia,  muscular  and  articular  sensations  are 
both  involved.  The  degree  of  this  can  be  accurate- 
ly measured  by  the  ataxiagraph  (Figs.  33  and  34). 

With  the  eyes  open  a  healthy  person  stand- 
ing erect  with  feet  together  tends  to  sway  for- 
ward. The  antero-posterior  excursion  of  the 
head  averages  3.7  cm.  (1^  in.),  the  maximum 
being  9  cm.  (34-  in.).  The  lateral  excursion 
averages  1.9  cm.  (f  in.),  maximum  being  5.4 
cm.  With  the  eyes  closed  the  antero-posterior 
excursion  averages  3.4  cm.  (1^  in.),  maximum 
3^  in. ;  the  lateral  excursion  1.9  cm.  (If  in.), 
maximum  6.8  cm.  (2f  in.)     In  other  words,  the 


Fig.  3.3. —Ataxiagraph. 


so.  a.  N°5  2- 

Fig.  34.— Ataxiagrams.    No.  1,  Made  with  eyes  open; 
No.  2,  made  with  eyes  closed. 


person  normally  stands  a  little  steadier  with  the  eyes  closed,  the 
average  excursion  being  1|X|  in.  with  eyes  open,  l^Xf  in.  with 
eyes  closed  (Bullard  and  Brackett) .  * 

*  This  is  not  always  the  case. 


DIAGNOSIS    AXD    METHODS   OF    EXAMINATION". 


59 


Ataxia  of  motion  is  tested  by  the  gait.  The  patient  cannot  walk 
a  straight  line  and  cannot  walk  without  watching  the  floor  with  the 
eyes.  The  arms  cannot  be  moved  in  a  co-ordinate  way.  With  the 
eyes  closed,  the  patient  cannot  place  the  finger  on  the  tip  of  the 
nose,  or  lobe  of  the  ear,  or  any  indicated  spot.  Ataxia  of  motion 
involves  especially  the  articular  and  tendonous  sensations,  but  not 
these  exclusively.  It  may  be  measured  by  noting  how  close  in 
walking  the  patient  keeps  upon  a  given  line  ten  feet  long ;  how  near 
he  can  place  the  finger  upon  the  centre  of  a  board  marked  like  a 
target.  The  patient  is  placed  ten  feet  away,  and  made  to  walk 
directly  at  it  and  place  the  finger  in  the  centre. 

To  sum  up  the  foregoing,  we  have : 


Due  to 


Tested  by 


Ataxia 


Muscular  anaesthesia 

Articular  and  tendonous  anaesthesia. 
Combined  forms,  e.g. ,  static  ataxia. 
Locomotor  ataxia 


Weights,  etc. 
Position  of  limbs. 
Co-ordinate  movements. 
Station  and  gait. 


Vision. — The  special  modes  of  examination  are  given  under  the 
head  of  Diseases  of  the  Optic  Xerve  and  Ocular  Muscles.  The 
special  points  which  the  neurologist  must  investigate  are  visual 
acuity,  astigmatism,  errors  of  refraction,  limitation  of  the  visual 
field,  exophthalmia,  retraction  of  the  bulb,  color  blindness,  the  state 
of  the  pupil  and  its  reflexes. 

Hearing. — The  special  methods  of  examination  are  given  else- 
where. The  points  chiefly  to  be  investigated  are  acuity,  range,  bone 
conduction,  aerial  conduction,  electrical  reactions. 

Sense  of  Smell  and  Sense  of  Taste. — See  cranial  nerves. 


CHAPTER   VI. 

HYGIENE,    PROPHYLAXIS,    TREATMENT. 

In  the  treatment  of  nervous  disease,  the  physician  attempts  to 
relieve  distressing  symptoms,  to  secure  radical  cure,  and  to  prevent 
return.  This  calls  for  various  measures,  which  may  be  classed  under 
the  heads  of  general  hygiene,  diet,  exercise,  climate,  hydrotherapy, 
massage  in  various  forms,  electricity,  drugs,  external  applications, 
and  surgical  intervention. 

General  Hygiene. — To  secure  and  keep  steady  nerves,  and  to 
prevent  the  supervention  of  organic  nervous  disease,  would  require 
a  considerable  reconstruction  of  the  present  social  system.  I  can 
only  give  some  hints  as  to  the  kind  of  advice  physicians  should  give 
to  help  along  the  desired  end,  this  being  meant  more  especially 
for  the  neuropath.  Thus  two  people  of  very  nervous  tempera- 
ment should  not  marry.  Blood  relations  of  the  same  temperament 
should  not  marry,  and  families  with  a  psychopathic  taint  should 
not  intermarry.  Children  should  be  brought  up  to  eat  slowly 
a  mixed  diet,  to  sleep  early  and  long,  to  play  in  the  open  air,  to 
learn  self-control  and  obedience.  Their  parents  should  keep  from 
them  all  infective  fevers.  Systematic  study  and  work  are  good  for 
all  children.  It  is  the  strain  due  to  defective  vision,  poor  light  and 
ventilation,  and  unsuitable  tasks  that  hurts  the  neurotic.  Educa- 
tion and  occupation  are  the  best  kind  of  builders  up  of  healthy 
nerves.  There  are  children,  however,  who  cannot  follow  the  ordi- 
nary educational  lines  and  who  must  be  specially  trained  in  conse- 
quence. The  queer  and  eccentric  children  with  some  twist,  or  pre- 
cocious talent,  need  especial  care.  They  usually  must  be  brought 
up  to  follow  lives  on  a  low  mental  plane.  Too  many  good  farmers 
and  artisans  are  spoiled  by  being  made  poor  professional  men,  or 
being  set  up  in  responsible  business  positions.  Adults  need  to  keep 
in  mind  only- — moderation,  exercise,  and  the  avoidance  of  a  luetic 
infection.  With  these  they  need  not  fear  the  use  of  alcohol,  to- 
bacco, tea,  coffee,  or  even  occasional  irregularities  in  sleeping  and 
eating.  Physical  and  mental  shocks,  infective  fevers,  and  poisons 
are  prolific  promoters  of  nervous  disease.  Syphilis  stands  out  as 
the  most  important  single  factor  in  producing  organic  nervous 
diseases.  If  it  could  be  removed  we  would  have  little  if  any  loco- 
motor ataxia,  paresis,  or  myelitis,  and  far  fewer  cases  of  apoplexy. 


HYGIENE,    PROPHYLAXIS,    TREATMENT.  61 

Alcohol  is  a  less  important  factor,  but  does  much  to  produce 
mental  disease,  vascular  disease,  and  hereditary  degeneration. 

Diet. — For  the  neuropathic  in  general,  the  best  diet  is  a  nitro- 
genous one,  but  it  should  contain  some  fat.  Water  should  be  drunk 
plentifully  except  by  the  obese,  while  the  total  amount  of  food 
should  be  less  than  when  severe  muscular  exercise  is  taken.  The 
best  foods  are  meats,  especially  fowl ;  fish,  eggs,  milk,  buttermilk, 
cocoa,  green  vegetables,  and  stale  bread  with  plenty  of  butter. 
If  there  is  a  tendency  to  constipation,  farinaceous  foods  and  green 
vegetables  may  be  made  the  prominent  articles  of  diet  in  one  of 
the  daily  meals,  and  stewed  fruit  and  some  alkaline  water  added. 
Milk  is  not  a  very  good  food  for  adults  or  the  aged,  except  in  mod- 
erate amount.  The  drinks  of  brain  workers  should  be  mainly  plain 
and  alkaline  waters.  Alcohol  can  be  taken  in  moderation  by  some 
1  train  workers  without  harmful  results.  It  may  even  secure  an  in- 
creased capacity  for  work,  but  this  is  rarely  the  case  in  the  Ameri- 
can climate. 

In  persons  of  an  especially  irritable  nervous  system  those  who 
arc  classed  popularly  as  ''nervous,"  neurasthenic,  or  hysterical,  the 
above  rules  apply  as  to  a  nitrogenous  diet,  plus  as  much  fat  as  can 
be  digested.  There  is  a  class  of  nervous  persons  who  of  themselves 
find  that  they  cannot  take  anything  sweet  without  producing  head- 
aches, rheumatic  pains,  and  dyspeptic  symptoms.  These  persons 
should  live  on  meats,  fish  with  butter,  oysters,  cream  and  milk,  cod- 
liver  oil,  and  fat  pork.  Beef  tea  with  the  white  of  an  egg  or  some 
peptonoids  forms  a  very  nutritious  dish.  It  has  been  the  canon  of 
medicine  for  many  years  that  animal  food  must  be  the  soul  of  the 
neurotic's  diet.  Most  nervous  persons  find  in  addition  that  green 
vegetables  like  spinach  agree  very  well  with  them.  Stale  bread  can 
betaken  twice  a  day  lively,  plenty  of  butter  being  used  upon  it.  The 
dietetic  breads  from  which  the  starch  lias  been  removed  arc  some- 
times useful,  but  are,  as  a  rule,  unpalatable,  and  soon  cause  disgust. 

When  a  rigid  diet  is  to  be  laid  flown,  there  is  no  better  list  for 
nervous  invalids  than  the  following:  fowl;  beef;  mutton  and  Lamb; 
fish,  boiled  or  broiled;  oysters;  milk;  butter;  eggs,  raw  or  soft- 
boiled;  cocoa;  graham  bread  and  gluten  bread;  spinach;  Brussels 
sprouts;   string  beans;   stewed  fruits. 

Some  neurotic  persons  seem  to  need  a  great  deal  of  food,  but 
as  a  rule  harm  conies  from  full  diets,  and  one  cannot  get  Strong  by 
stuffing. 

The  frankly  nervous  and  especially  the  hysterical  patients 
should  not  use  alcohol  at  all.  Tea  and  coffee  can  lie  taken  in  very 
small  amount,  and  best  without  sugar.  The  various  alkaline  min- 
eral waters  may  be  used  temperately  with  impunity,  hut    none   of 


62  DISEASES    OF   THE    NERVOUS    SYSTEM. 

thein  have  much  specific  effect  in  relieving  nervousness  or  curing 
the  nervous  temperament. 

Water  should  be  drunk  between  or  before  meals  and  a  moderate 
amount  at  meals.  At  least  three  pints  of  liquid  should  be  taken 
daily.  American  neurotics  do  not  drink  water  enough.  They  have 
half-desiccated  nerves,  and  desiccation  increases  nervous  irrita- 
bility. An  exclusive  milk  diet  is  indicated  in  some  forms  of  hys- 
teria, hypochondriasis,  and  neurasthenia  accompanied  with  dys- 
pepsia. Karell's  method  is  to  give  four  to  eight  ounces  of  warm 
skim  milk  at  8  a.m.,  12 m.,  4  p.m.,  and  8  p.m.  The  amount  is  grad- 
ually increased.  Such  diets  are,  however,  only  to  be  kept  up  for  a 
limited  time. 

Exercise*—  As  a  prophylactic,  against  nervous  disorders,  the  value 
of  exercise,  if  taken  out  of  doors,  can  hardly  be  overestimated. 
Brain  workers  are  better  for  moderate  exercise,  but  they  do  not  need 
much;  and  after  twenty-five,  severe  intellectual  work  can  rarely  be 
done  by  persons  in  athletic  training.  Before  the  age  of  twenty -five, 
when  the  system  is  exuberant  with  vitality,  hard  study  and  hard 
physical  exercise  can  be  pursued  successfully  together  by  some. 
Persons  of  a  neuropathic  constitution  are  most  benefited  by  regular 
exercise  when  it  interests  the  mind.  In-door  gymnasium  exercise 
with  the  ordinary  apparatus  does  little  good  except  through  the 
bath  that  follows  it.  In  many  forms  of  chronic  organic  nervous 
disease,  exercise  is  to  be  prohibited.     These  will  be  discussed  later. 

The  best  forms  of  exercise  are  those  which  take  one  out  of  doors, 
interest  the  mind,  and  call  into  play  the  muscles  of  the  chest  and 
arm.  Walking  fulfils  but  two  and  often  only  one  of  these  condi- 
tions. Calisthenics  are  useful  when  they  interest  and  are  vigor- 
ously done.  Horseback  riding,  golfing,  and  bicycling  fulfil  best  the 
conditions  required  for  a  good  form  of  exercise.  And  bicycling  is 
the  cheaper,  more  practicable,  and  generally  better  liked  of  these. 
Lawn  tennis,  badminton,  golf,  are  all  exercises  which  can  be  taken 
up  by  both  sexes  and  at  nearly  all  ages.  Exercise  is  not  so  neces- 
sary and  should  be  taken  in  moderation  after  forty  or  forty-five. 

Hydrotherapy. — Hydrotherapy  is  the  science  of  applying 
water  in  the  treatment  of  disease.  The  modes  by  which  it  is  used 
in  neurological  therapeutics  are : 

I.  General  hydrotherapy : 

1.  Tonic  hydrotherapy. 

2.  Sedative  hydrotherapy. 

3.  Indifferent  baths  for  mechanical  purposes. 

II.  Local  hydrotherapy. 

1.  Tonic  Hydrotherapy. — For  purposes  of  stimulating  nutrition 
and  increasing  vasomotor  tone  we  employ  cold  plunges,  the  rain 


HYGIENE,    PROPHYLAXIS,    TREATMENT.  63 

bath  or  shower,  the  jet,  cold  sponging,  cold  sitz  baths,  cold  sheets, 
local  applications  of  ice  or  cold  compresses,  or  cold  rubbing,  ice 
bags,  brine  baths,  brief  cold  packs,  and  sea  bathing. 

The  cold  plunge.  The  patient  fills  the  bathtub  with  water  at 
from  60°  to  70°  F.  He  then  gets  in,  and  at  once  jumps  out  and 
rubs  himself  vigorously  until  reaction  occurs. 

The  rain  bath  and  Charcot  douche.  The  patient  stands  in  a 
tub. with  the  feet  preferably  in  warm  water,  and  allows  the  cold 
water  to  fall  on  the  back  and  rest  of  the  body  for  one  or  two 
minutes.  Or  a  solid  jet  of  cool  water  is  thrown  with  force  upon  the 
back  of  the  patient,  by  an  attendant  who  stands  ten  or  twelve  feet 
away  (Charcot  douche).  The  cold  jet  may  be  alternated  with  a 
warm  one  (Scottish  douche). 

The  cold  sheet  or  drip  sheet  is  used  by  wringing  a  cotton  sheet 
out  in  cold  water  and  wrapping  it  sudddeuly  about  the  patient,  who 
sits  or  stands  with  the  feet  in  a  tub  of  warm  water.  The  patient 
is  then  dried,  put  to  bed,  and  vigorously  rubbed. 

Ice  bags  are  worn  upon  the  spine  for  one  or  two  hours  once  or 
twice,  or  oftener,  daily;  or  they  may  be  applied  for  one  or  two 
hours  at  night. 

Most  of  the  above  measures  have  a  general  stimulating  and  tonic 
effect. 

Cold  baths  in  their  various  forms,  but  especially  the  jet  baths 
like  the  Charcot  douche,  are  best  preceded  by  a  short  stay  in  a  hot 
box  until  the  patient  begins  to  perspire. 

The  half-bath  and  wash-off  consists  of  a  tub  partly  filled  with 
water  at  a  temperature  of  65°  to  70°  F.  The  water  only  half  covers 
the  reclining  body.  While  lying  in  it,  the  patient  is  vigorously 
rubbed.  A  cold  cloth  may  be  laid  on  the  head.  After  five  to 
twenty  minutes,  affusions  of  colder  water  are  poured  over  the 
shoulders.     The  bath  may  be  made  as  warm  as  80 ;  at  first. 

Brine  baths  contain  about  two  per  cent,  of  salt,  this  being  about 
the  amount  in  sea  water — twenty -five  pounds  to  thirty  gallons  of 
water.  They  are  given  at  a  temperature  of  100°  F.  for  twenty  to 
thirty  minutes  daily,  or  cool  baths  at  a  temperature  of  70  F.  may 
be  given  for  five  to  ten  minutes,  the  patients  exercising  meanwhile. 

Physiology. — Cold  applications  produce  a  local  contraction  of 
blood-vessels,  followed  by  dilatation.  There  are  usually  increased 
tissue  metamorphosis,  increased  secretion  of  urine,  increased  absorp- 
tion of  oxygen,  and  increased  excretion  of  carbonic  acid.  In  non- 
febrile  persons,  cold  applications  abstract  some  heat,  but  they  also 
Stimulate  the  heat-producing  centres,  so  that  the  total  effect  is  to  in- 
crease the  heat  of  the  body.  Only  very  cold  or  prolonged  baths  les- 
sen heat  production  as  well  as  excretion  of  C02.     Cold  baths  at  first 


64  DISEASES   OF  THE   NERVOUS   SYSTEM. 

accelerate  and  then  tend  to  retard  pulse  and  respiration.  Cutaneous 
sensibility  is  at  first  increased.  After  a  cold  bath  there  is  a  sense 
of  exhilaration  and  increased  muscular  power,  provided  the  bath  be 
not  too  cold  or  too  long  continued.  The  duration  necessary  to  pro- 
duce a  reaction  varies  with  different  people,  and  some  weak  and 
sensitive  patients  never  can  be  made  to  react.  Cold  baths  sys- 
tematically taken  furnish  a  kind  of  vasomotor  gymnastics.  The 
neuro-mechanism  controlling  the  blood-vessels  becomes  more  supple, 
and  the  tendency  to  local  congestion  of  the  viscera  and  mucous  mem- 
branes is  prevented.  The  shower  and  jet  furnish  the  most  valuable 
means  of  securing  tonic  effects  in  nervous  disorders.  These  are 
not  used  with  cold  water  alone.  It  is  often  better  to  apply  at  first 
a  warm  stream  at  95°  or  105°  F.,  and  then  gradually  lower  it,  or 
to  apply  the  hot  aud  cold  jets  alternately.  In  this  way  tonic  effects 
can  be  obtained  even  with  very  feeble  persons. 

2.  Sedative  Hydrotherapy. — The  sedative  baths  are  the  luke- 
warm bath,  the  w^t  pack,  Turkish  and  Russian  baths,  the  hot  sitz 
baths,  pedal  baths,  compresses  and  fomentations,  and  hot- water 
bags. 

The  lukewarm  bath  is  given  at  a  temperature  of  95°  to  98°  F. 
for  ten  minutes  to  half  an  hoar  daily.  If  a  slight  tonic  effect  is  de- 
sired also,  the  patient  should  receive  an  affusion  afterward,  i.e., 
basins  of  cool  water  at  60°  to  70°  F.  should  be  poured  over  the 
shoulders.  The  addition  of  salt  or  of  pine-needle  extract  is  often 
useful. 

The  wet  pack.  A  large,  thick  blanket  is  spread  upon  the  bed, 
and  upon  this  is  laid  a  linen  or  cotton  sheet  wrung  out'  in  cold 
water,  40°  to  6(T  F.  The  nude  patient  lies  on  this,  and  the  sheet 
is  then  smoothly  wrapped  about  him,  the  head  and  feet  not  being 
included.  The  sheet  is  carried  between  the  legs  and  made  to  lie 
evenly  in  contact  with  the  body.  Then  the  blankets  are  folded  over 
him,  and  other  blankets  may  be  piled  upon  this.  Sometimes  it  is 
well  to  place  hot-water  bottles  at  the  feet  and  a  cool  compress  on 
the  head.  The  patient  lies  in  this  pack  for  thirty  to  forty-five 
minutes  and  is  then  rubbed  off.  A  cool  affusion  may  be  given  first. 
With  delicate  patients  it  is  well  at  first  simply  to  wrap  the  patient 
in  warm  flannels  until  free  perspiration  results,  then  give  a  cold  affu- 
sion or  wash-off  and  rubbing. 

In  Turkish  baths  the  patient  is  exposed  to  a  temperature  at  first 
of  130°  or  140°  F.  for  fifteen  to  thirty  minutes,  and  then  to  one  of 
160°  or  200°  F.  for  a  shorter  time.  This  is  followed  by  massage 
and  a  cold  affusion  or  plunge  or  shower.  The  effects  of  these  baths 
are  somewhat  tonic  if  not  too  prolonged.  The  patient  should  never 
go  into  the  hotter  rooms  until  he  perspires,  and  he  should  select 


HYGIENE,  PROPHYLAXIS,  TREATMENT.  65 

bathrooms  that  are  well  ventilated.  Russian  baths  have  similar 
effects,  but  the  bodily  temperature  is  raised  to  a  higher  degree  in 
them  than  in  Turkish,  owing  to  the  lessened  amount  of  perspiration 
due  to  the  presence  of  steam. 

Hot  sitz  baths.  The  patient  sits  in  water  at  a  temperature  of 
100°  to  125°  F.  for  twenty  or  thirty  minutes.  Sometimes  mustard 
is  added.  Cold  sitz  baths  are  given  in  the  same  way,  and  are  often 
useful  in  sexual  neurasthenia. 

Hot  compresses  consist  of  layers  of  flannels  wrung  out  in  hot 
water  and  covered  with  dry  flannels  and  rubber  cloth.  They  are 
used  to  relieve  local  pains  and  inflammations.  They  may  be  applied 
over  the  abdomen  for  insomnia.  Hot  sprays  and  douches  are  used 
for  similar  purposes  as  fomentations.  The  hot  spinal  bag  is  applied 
at  a  temperature  not  above  120 c  F. 

Physiology. — Warm  baths,  if  applied  in  the  form  of  the  moist 
pack,  followed  by  sponging  with  tepid  water,  lessen  temperature  by 
increasing  heat  radiation  and  conduction.  If  applied  so  as  to  pre- 
vent radiation,  the  bodily  heat  is  raised.  Warm  baths  increase  the 
circulation  of  the  skin,  lessen  cutaneous  sensibility,  withdraw  blood 
from  the  central  organs,  increase  the  exhalation  of  CO„,  but  lessen 
the  respiratory  activity  on  the  whole.  Nitrogenous  metabolism  is 
increased  by  from  two  to  three  per  cent.,  and  more  urea  is  excreted. 
Pulse  and  respiration  are  increased.  Nervous  excitement  is  less- 
ened, and  the  general  effect  is  to  cause  sedation  and  a  feeling  of 
languor.  The  wet  pack  is  a  most  useful  sedative  in  neurasthenia 
and  insomnia,  and  may  take  the  place  of  medicinal  sedatives,  like 
the  bromides.  It  should  be  given  three  or  four  times  weekly,  or  for 
a  short  time  dailv.  The  lukewarm  bath  ranks  next  in  its  sedative 
efficacy.  It  is  believed  that  applications  of  water  to  the  feet  and 
abdomen  especially  affect  the  intracranial  circulation ;  given  to  the 
thigh  and  wrists,  the  pulmonary  circulation;  cold  causing  conges- 
tion, and  heat  anaemia,  of  the  distant  parts.  Cold  to  the  spine  is 
believed  to  cause  at  first  constriction,  and  later  dilatation,  of  the 
thoracic,  abdominal,  and  pelvic  vessels;  heat  has  the  opposite  effect. 
Hence  cold  applications  are  used  to  relieve  cold  feet  and  anaemic 
conditions  of  the  viscera. 

The  fact  must  be  borne  in  mind  that  cold  baths  and  frequent 
bathing  of  any  kind  debilitate  some  few  persons.  Special  details 
of  hydrotherapy  are  given  in  the  appendix. 

Massage. — The  term  massage  may  be  made  to  include  all  the 
manipulations  of  the  body  for  the  purpose  of  curing  disease.  The 
different  methods  of  applying  it  as  classified  by  Jacoby  are: 

Effleurage  or  gentle  stroking.  The  maximum  force  to  be  applied 
here  should  not  exceed  the  weight  of  the  hand.  Massage  a  friction 
5 


66  DISEASES   OF   THE   NERVOUS   SYSTEM. 

or  rubbing.  Energetic  strokes  with  one  hand  and  strong  circular 
or  to-and-fro  friction  with  the  other.  Petrissage  or  kneading. 
Tapotement  or  percussion  with  the  fingers,  hands,  or  instruments. 
Functional  movements,  passive,  active,  and  combined  with  move- 
ments made  by  the  operator.  The  physician  may  be  reminded  that 
a  male  operator  is  a  masseur,  a  female  a  masseuse,  and  that  the 
patient  is  massed. 

Massage  accelerates  the  lymph  and  venous  currents,  and  thus 
promotes  absorption.  It  increases  at  least  temporarily  the  number 
of  red  blood  cells  (Mitchell).  It  increases  the  rapidity  and  force  of 
the  heart  beat  (except  abdominal  massage,  which  slows  the  heart) 
and  helps  to  relieve  local  congestions  and  inflammatory  deposits. 
It  presses  and  stretches  the  terminal  nerve  filaments,  increases  the 
irritability  of  motor  nerves  and  the  contractility  of  muscles.  It 
may  either  increase  or  lessen  the  irritability  of  sensory  nerves 
according  as  it  is  applied.  Of  the  various  forms  of  massage,  tapote- 
ment is  frequently  useful,  and  is  the  kind  often  used  in  neuralgias. 
It  is  applied  not  only  with  the  fingers  and  hand,  but  also  by  the  aid 
of  rubber  tubes  known  as  muscle  beaters,  rubber  balls  with  rattan 
or  whalebone  handles,  percussion  hammers,  and  various  percuteurs. 

Regular  muscular  movements  according  to  a  certain  fixed  sched- 
ule are  used  in  the  treatment  of  locomotor  ataxia  and  paralysis 
agitans.  The  details  of  these  exercises,  known  as  the  method  of 
Fraenkel,  will  be  given  later. 

Massage  is  of  considerable  value  in  certain  forms  of  atonic  neu- 
rasthenia and  hysteria  associated  with  anaemia,  dyspepsia,  and 
feeble  circulation,  in  hemiplegia,  in  the  paralyses  of  peripheral 
origin,  iu  functional  spas^n,  especially  in  some  forms  of  writer's 
cramp  and  allied  neuroses,  in  cerebral  hyperemia,  insomnia,  con- 
stipation, and  in  headache  and  some  neuralgias,  especially  those 
about  the  head,  neck,  and  arm.  It  is  contraindicated  in  heart  dis- 
ease, arteritis,  or  when  there  is  danger  of  dislodging  a  thrombus. 

Climate  isr  Nervous  Diseases. — The  factors  which  make  up  a 
special  kind  of  climate  are :  Purity  of  air;  temperature;  humidity; 
sunlight;  rarefaction  of  the  air;  ozone;  wind;  electricity;  soil; 
trees;  social  conditions. 

Kegarding  these  points,  some  facts  are  very  well  settled.  The 
air  in  the  country  is  purer  than  in  cities.  The  air  on  the  sea  and 
at  high  levels  is  purer  than  in  other  localities.  The  temperature 
above  the  sea  level  diminishes  about  1°  F.  for.  every  300  to  350  feet, 
and  is  less  the  dryer  the  air.  Alterations  in  temperature  are  less 
near  the  sea  and  less  in  the  southern  hemisphere.  The  higher  the 
elevation  and  the  colder  the  air,  the  less  moisture  does  it  contain. 


HYGIENE,    PROPHYLAXIS,    TREATMENT.  67 

About  the  factors  of  ozone  and  electricity  in  the  air  little  definite  is 
known. 

Climates  are  classified  by  Weber  into  marine  low-level  inland, 
and  high-level  inland.  These  all  have  great  variations  in  quality, 
depending  upon  their  temperature,  moisture,  etc.  As  a  general 
rule,  warm  marine  climates  and  sea  voyages  are  best  for  neuras- 
thenic invalids  of  the  irritable  type.  On  the  other  hand,  in  atonic 
and  anaemic  conditions  high  inland  climates  are  better,  at  least  for 
a  time.      Such  climates  should  not  be  too  dry  or  windy. 

In  organic  degenerative  diseases  of  the  nervous  system,  marine 
climates  and  low  levels  are  better. 

Germany,  the  Eiviera,  the  Bermudas,  the  West  Indies,  southern 
Colorado,  Arizona,  and  southern  California  are  favorite  places  for 
sending  neurasthenic  Americans.  Camp  life  in  the  Adirondacks  or 
other  forests  is  also  found  most  useful. 

Electricity  in  Nervous  Diseases. 

Physical.  — Electricity  is  assumed  to  be  a  material  like  a  fluid, 
perhaps  a  condition  of  the  ether  itself.  It  is  not  a  force  any  more 
than  water  is  a  force,  but  it  produces  force  by  its  movements. 
Electrical  phenomena  are  the  result  of  the  strain  or  stress  put  upon 
the  electrical  fluid  (Lodge).  Physicists  assume  that  the  electrical 
fluid  exists  in  two  conditions,  positive  and  negative,  and  we  speak 
of  positive  electricity  and  negative  electricity  accordingly.  Under 
ordinary  conditions  these  fluids  are  united  and  in  equilibrium ;  but 
by  certain  agencies,  such  as  friction,  heat,  chemism,  etc.,  they  can 
be  separated.  We  assume  that  the  condition  of  electrical  equi- 
librium is  that  of  zero,  and  that  the  earth's  electricity  is  at  zero. 
Positive  electricity  is  raised  above,  negative  electricity  pulled  be- 
low, this  zero  point.  Electrical  phenomena  result  from  attempts 
of  the  fluids  to  become  equalized  or  stable  again  at  the  zero  point, 
just  as  the  phenomena  of  heat  result  from  differences  of  tempera- 
ture and  those  of  gravity  from  difference  of  pressure.  The  distance 
to  which  the  electrical  fluids  are  separated  from  the  zero  point  is 
spoken  of  as  the  difference  in  "potential."  This  potential  corre- 
sponds to  the  term  "degrees"  in  measuring  heat.  Now,  the  greater 
the  difference  in  potential,  the  greater  the  effort  of  the  fluids  to 
return  to  zero.  High  and  low  potentials  correspond  to  high  or  low 
intensity  of  heat.  Tension  is  the  result  of  the  widely  separated 
fluids  striving  to  return  to  the  zero  point.  It  is  the  same  thing  as 
difference  of  potential,  and  the  term  may  as  well  be  dropped.  When 
the  two  fluids,  at  different  potentials,  attempt  to  become  equalized, 
they  pass  along  certain  paths  and  form  electrical  currents.     Elec- 


68  DISEASES    OF   THE    NERVOUS   SYSTEM. 

tricity  will  pass  along  any  substance,  but  some  substances  conduct 
it  more  easily  than  others,  and  these  are  known  as  conductors.  The 
relative  value  of  different  conductors  is  shown  in  the  following  table : 

1.  The  metals;  2,  charcoal  ;  3,  plumbago;  4,  dilute  acids;  5, 
saline  solutions;  6,  pure  water;  7,  living  animals;  8,  flame.  Of 
the  metals,  silver  and  copper  are  the  best  conductors.  The  human 
body  would  have  about  the  same  conductibility  as  the  saline  solu- 
tions, if  it  were  not  for  the  skin,  which  is  a  very  poor  conductor, 
especially  when  it  is  dry.  Those  substances  along  which  electricity 
passes  with  great  difficulty  are  known  as  non-conductors  or 
insulators.  The  following  is  a  list  of  some  of  these,  the  substances 
arranged  in  accordance  with  their  relative  value : 

1.  Caoutchouc.  2.  Silk.  3.  Glass.  4.  Wax.  5.  Sulphur. 
6.  Eesins.     7.   Shellac.     8.  Dry  air. 

The  electrical  fluids  may  .be  kept  by  insulators  at  different 
potentials,  the  insulators  preventing  them  from  becoming  equalized 
or  reduced  to  the  same  potential.  Electricity  in  this  condition  is 
called  static.     Its  study  is  called  electrostatics. 

The  electric  fluid  in  motion  is  called  dynamical  electricity,  and 
its  study  is  electrodynamics. 

Technical  Terms. — There  are  certain  technical  terms  which  it  is 
necessary  to  understand.  Electromotive  force  (symbol,  EMF)  is  the 
force  which  tends  to  set  electricity  in  motion.  An  electric  current 
results.  The  current  strength  (symbol,  C)  is  the  term  used  to  ex- 
press the  capacity  of  the  separated  fluids  to  overcome  resistance  in 
their  attempts  to  reach  equilibrium  or  equalization  again.  This 
current  strength,  or  simply  the  current,  naturally,  is  in  proportion 
to  the  strength  of  the  electromotive  force,  which  is  constantly  dis- 
sociating the  electrical  fluids  and  generating  the  current.  If,  how- 
ever, as  is  always  the  case,  the  electrical  fluid  meets  resistance  in 
seeking  equilibrium,  the  resistance  diminishes  its  current.  Hence 
we  have  the  formula  known  as  Ohm's  law : 

„  ,        Electromotive  force  _,      EMF 

Current  strength  = ^ — r— ;  or  O  =     p    . 

°  Resistance  K 

All  bodies  offer  some  resistance  to  electrical  currents,  and  it  is 
important  to  have  some  standard  unit  of  resistance  for  the  sake  of 
comparison.  Such  standard  unit  has  been  adopted  and  is  called  an 
ohm.  It  is  the  resistance  offered  to  a  current  by  a  certain  piece  of 
wire  of  definite  size  and  length. 

A  volt  is  the  unit  of  electromotive  force,  i.e.,  it  represents  the 
force  which  will  generate  a  certain  amount  of  electricity  in  a  second 
of  time.     A  Daniell  cell  is  of  not  quite  one  volt  strength. 

An  ampere  is  the  unit  of  working  power  or  current  strength.     It 


HYGIENE,    PROPHYLAXIS,    TREATMENT.  69 

is  the  current  strength  produced  by  one  volt  of  electromotive  force 
working  against  one  ohm  of  resistance.  A  milliampere  is  one- 
thousandth  of  an  ampere.     A  watt  is  the  unit  of  work. 

When  a  given  current  flows  along  from  a  large  into  a  small 
conductor,  the  quantity  in  this  latter  conductor  in  a  given  section 
is  greater  and  the  currerjt  is  said  to  be  denser.  The  instrument  by 
which  the  strength  of  a  current  is  measured  is  known  as  the  am- 
peremeter: in  medical  practice,  only  fractions  of  the  ampere  are 
used,  and  the  instrument  is  called  the  millicnnjjeremeter.  A  rheostat 
is  an  instrument  for  interposing  resistance  in  a  current. 

Electrical  Appliances. — The  batteries  used  in  neurological 
practice  are  of  three  kinds :  the  static,  the  f  aradic,  and  the  galvanic. 

The  static  electrical  batteries  are  mostly  modifications  of  the 
Holtz  influence  machine.  They  are  inclosed  in  glass  to  prevent  the 
effects  of  moisture.  The  instruments  made  in  this  country  for 
medical  purposes  will  usually  furnish  electricity  all  the  year  round. 
The  battery  accessories  consist  of  an  insulated  stool  and  brass-ball 
electrodes  with  glass  handles.  The  patient  is  placed  on  the  stool, 
which  is  connected  by  a  rod  with  one  of  the  prime  conductors.  The 
battery  being  started,  the  patient  becomes  enveloped,  as  it  were, 
with  a  layer  of  electricity  which  is  at  a  very  high  potential  and  con- 
stantly flying  off,  being  retained  only  by  the  dry,  non-conducting 
air.  The  electrode  held  by  the  operator,  and  connected  directly  or 
indirectly  to  the  other  prime  conductor,  is  now  brought  near  the 
patient.  The  electrical  fluid  bounds  to  the  zero  point  with  such 
force  that  some  of  the  metallic  parts  of  the  electrode  are  carried  off 
and  ignited,  causing  the  disruptive  spark.  The  patient  thus  is  dis- 
charged of  the  fluid;  but  it  continually  reaccumulates  upon  him, 
and  thus  one  can  keep  on  drawing  sparks  from  all  parts  of  the 
body.  The  electric  spark  causes  a  muscular  contraction  and,  a  little 
later,  a  small  punctate  red  spot.  There  is  some  pain  connected 
with  it,  but  as  the  electricity  penetrates  the  body  for  only  an  in- 
finitesimal period  of  time,  it  directly  affects  the  viscera  but  little 
and  is  not  dangerous.  Various  ingenious  electrodes  have  been 
devised  for  modifying  the  character  of  the  static  discharge,  but  they 
all  have  much  the  same  effect  as  the  spark. 

By  approximating  the  prime  conductors  so  that  they  almost 
touch,  and  then  connecting  the  outer  surface  of  the  two  Leyden  jars 
which  hang  from  the  prime  conductors  with  sponge  electrodes,  one 
gets  the  static  induced  current  described  by  Dr.  William  J.  Morton. 
The  special  peculiarity  of  this  current,  as  well  as  of  the  spark 
discharge,  is  that  it  is  made  up  of  electricity  at  a  very  high  poten- 
tial, and  that,  being  composed  of  oscillating  or  alternating  currents 
of  extremely   short  duration,    the  quantity   of   electricity   is  very 


70  DISEASES   OF   THE    NERVOUS   SYSTEM. 

small.  The  result  is  that  when  a  muscle  degenerates,  it  loses  its 
irritability  to  the  static  current  very  early.  The  static  current  will 
thus  reveal  a  beginning  degeneration  of  nerve  sooner  than  the  other 
currents;  it  also  promotes  tissue  changes  more  than  other  forms. 
It  sometimes  stimulates  a  greatly  degenerated  muscle,  so  that  later 
the  other  forms  will  produce  a  contraction.  It  has  a  powerful  psy- 
chical effect,  and  lends  itself  readily  to  quackery. 

In  farad ic  medical  batteries  the  electricity  is  produced  by  induc- 
tion. The  chief  elements  are  a  cell  and  two  coils  of  insulated 
copper  wire.  One  coil  is  placed  around  the-  other,  the  outer  coil 
being  longer  and  of  finer  wire.  The  cell  generates  a  current  which 
in  turn  *'  induces"  the  electricity  which  is  received  by  the  patient. 
The  original  current  is  so  arranged  that  it  is  being  constantly  broken 
and  closed  or  "made"  again.  At  both  break  and  make,  a  current 
is  induced  in  the  inner  coil  of  coiled  wire;  this  forms  what  is  called 
the  primary  induced  current  and  is  made  up  of  a  succession  of  short 
currents.  This  current,  though  theoretically  alternating,  is  really 
a  current  of  one  direction.  For  the  "  make"  current  is  opposed  and 
nullified  by  the  original  or  battery  current.  The  same  is  true  of 
the  secondary  induced  current  which  is  excited  in  the  outer  coil  by 
the  currents  of  the  inner  coil.  Both  currents  are  really  composed 
of  a  rapid  series  of  single  currents  going  the  same  wa}',  and  they 
each  have  a  positive  and  a  negative  pole.  The  primary  current  is 
one  of  lower  tension,  and  is  rather  less  strong.  It  can  be  used  when 
the  resistance  of  the  parts  is  not  great  and  a  very  powerful  current 
is  not  needed.  The  secondary  current  is  one  of  higher  tension,  it 
overcomes  resistance  better,  and  can  be  employed  in  connection  with 
the  wire  brush  and  in  anaesthetic  conditions.  It  is  also  the  current 
used  in  measuring  the  strength  of  the  faraclic  application,  as  will  be 
shown  later.  The  current  of  the  secondary  coil  resembles  that  of  the 
static  induced  current.  It  has,  however,  a  lower  potential,  vastly 
slower  alternations,  and  more  quantity.  It  can  contract  muscle, 
which  the  static  current  cannot  affect.  The  secondary  coil  should 
be  made  of  wire  of  a  standard  size,  length,  and  layers  of  coil.  A 
standard  coil  of  wire  800  metres  long,  .225  mm.  in  diameter,  wound 
on  a  spool  100  mm.  long,  is  quite  generally  adopted  now. 

Faraclic  batteries  are  made  with  the  zinc-carbon  or  Grenet  cell, 
the  Leclanche,  the  silver-chloride  cell,  or  some  modification  of  these. 
For  general  use,  the  zinc-carbon  cell  is  the  most  trustworthy;  but 
the  dry  silver-chloride  cell  is  the  most  convenient.  A  dry  cell 
made  with  muriate  of  ammonia  has  also  come  into  use.  Faraclic 
and  galvanic  currents  are  now  often  obtained  from  the  electric-light 
wire  now  so  generally  supplied  to  houses. 

Galvanic  Batteries. — There  are  two  kinds  of  these  in  practical 


HYGIENE,    PROPHYLAXIS,    TREATMENT. 


71 


use.  The  one  includes  the  cells  which  act  as  soon  as  the  circuit  is 
closed ;  the  other  includes  those  which  act  only  when  the  elements 
composing  the  battery  {e.g.,  zinc,  carbon,  platinum,  copper,  etc.) 
are  dropped  in  the  exciting  fluid.  The  former  class  (known  as  two- 
fluid  cells)  are  not  touched  except  to  renew  water  or  add  some 
chemical.  In  the  latter  (the  single-fluid  cells),  one  of  the  elements 
is  always  taken  from  the  fluid  when  the  current  is  not  in  use.  The 
first  class  of  cells  has  a  much  weaker  chemical  action  and  evolves 
less  electricity  in  a  given  time.  It  includes  the  Daniell  cell,  the 
gravity  cell,  the  Leclanche  cell,  and  the  silver-chloride  cell. 
Among  the  second  class  or  single-fluid  cells,  the  zinc-carbon  cell, 
known  as  the  Grenet  or  Stohrer's  cell,  already  referred  to,  is  most 
used.     The  best  portable  batteries  are  made  of  the  zinc-carbon  cell 


Tia.  85. — Author's  Electrode  Set. 


or  the  dry  chloride  of  silver  cells.  Stationary  or  office  batteries  are 
best  made  with  the  Leclanche  cell  or  some  modification  of  it;  or  the 
dry  silver-chloride  cell  may  be  used.  The  electric-light  current  can 
be  utilized  to  supply  continuous  and  interrupted  currents  and  for 
purposes  of  the  cautery.     It  is  expensive. 

The  ordinary  accessories  to  the  faradic  and  galvanic  batteries 
are  electrodes,  rheostat,  and  milliamperemeter. 

The  electrodes  needed  for  ordinary  purposes  are:  An  indifferent 
electrode  measuring  5  cm.  by  15  cm.  A  normal  electrode,  10  sq. 
em.  A  unit  electrode,  1  sq.  cm.  A  soft  wire  brush.  Three 
handles:  one  10  cm.  and  one  40  cm.  long,  one  short  handle  with  an 
interrupter.     A  milliamperemoter.     A  rheostat.     (See  Fig.  35.) 

Methods  of  Application. — Static  electricity  is  applied  for  fifteen 
or  twenty  minutes  daily  or  tri-weekly.  For  general  tonic  or  seda- 
tive effects,  sparks  are  drawn  from  all  parts  of  the  body  except  the 
face.     In  paralysis  or  spasm  or  pain,  sparks  arc  applied  to  1he 


72  DISEASES   OF   THE   NERVOUS   SYSTEM. 

affected  area.  For  headaches  and  cerebral  paresthesia?,  the  elec- 
trical breeze  is  very  useful,  but  it  must  be  strong. 

The  faradic  and  galvanic  currents  are  used  for  about  the  same 
time  and  intervals  as  the  static.  In  some  cases,  however,  the  gal- 
vanic current  should  be  given  daily  or  even  two  or  three  times  a 
day.  As  a  rule,  a  course  of  electrical  treatment  should  be  con- 
tinued for  six  to  eight  weeks,  and  then  discontinued  for  a  time. 

The  special  methods  used  in  applying  these  currents  are : 

1.  General  galvanization  and  faradization  or  general  electriza- 
tion. 

2.  Local  electrization  by  galvanization  of  the  brain,  of  the  neck, 
of  the  spine,  of  the  special  senses,  limbs,  and  viscera.  Or  by  fara- 
dization of  the  neck,  spine,  limbs,  and  viscera. 

3.  The  combined  faradic  and  galvanic  currents.  These  are 
given  by  means  of  the  De  Watteville  switch.  General  and  local 
electrization  can  be  given  in  this  way. 

4.  The  polar  method.  This  is  employed  chiefly  in  using  the 
galvanic  current.  The  indifferent  electrode  is  placed  on  the  sternum 
or  back,  and  the  other  electrode  applied  wherever  indicated. 

5.  Cataphoric  electrization  by  means  of  Peterson's  electrode. 

6.  Electrolytic  applications  are  used  in  enlarging  strictures  and 
affecting  inflammatory  deposits  and  neoplasms. 

In  general  electrization,  whether  galvanic  or  faradic,  the  indif- 
ferent electrode  is  placed  on  the  sternum,  feet,  or  back,  and  the 
other  pole  is  carried  over  the  limbs,  trunk,  neck,  and,  if  indicated, 
the  head.  In  some  cases,  however,  the  two  electrodes  are  applied 
together  upon  the  different  muscles  of  the  body.  In  local  electriza- 
tion, the  large  electrode  may  be  applied  on  an  indifferent  spot,  and 
the  other  applied  to  the  affected  limb  or  limbs,  or  the  two  electrodes 
may  be  used  together  on  the  same  segment  of  muscles.  There  are 
special  points  at  which  the  muscular  contraction  is  most  easily 
brought  out.  These  are  called  the  motor  points.  See  Figs.  36  to  41. 
In  the  ordinary  practice  of  applying  electricity  for  spinal-cord  dis- 
ease, with  galvanic  currents,  a  very  minute  amount  of  electricity 
reaches  the  cord.  With  large  electrodes,  however,  and  currents  of 
50  to  140  niilliamperes  the  cord  is  reached  with  a  current  of  -h  to 
1\  ma.  strength.  In  locomotor  ataxia  one  (positive)  electrode,  six 
by  twelve  inches,  is  placed  on  the  upper  part  of  the  back,  and  a  sec- 
ond electrode  of  the  same  or  larger  size  placed  on  the  abdomen,  the 
lowest  part  of  the  back,  the  legs,  and  the  perineum.  The  current 
should  be  increased  very  gradually  and  should  be  kept  on  for  only 
a  minute  in  each  place.  The  method  must  be  varied  somewhat 
according  to  the  size  and  sensitiveness  of  the  patient.     The  details 


HYGIENE,    PROPHYLAXIS,    TREATMENT.  73 

for  galvanizing  the  brain,  special  senses,  and  viscera  must  be  ob- 
tained from  special  text-books. 

When  an  electrode  is  held  steadily  upon  a  part,  it  is  called 


Fir..  40 


Ft.;.  39. 


Fig.  86  to  41.— Cuts  Showing  Motor  Points.  The  letters  refer  to  points  electrization 
of  which  stimulates  certain  muscles  to  contract.  These  points  vary  much  in  different  per- 
sons.    For  details  see  works  on  Medical  Electricity. 

stabile  ;  when  it  is  moved  over  it,  it  is  called  labile.  The  positive 
pole  is  called  the  anode  (An),  the  negative  the  cathode  (Ca).  The 
size  of  an  electrode  is  indicated  in  square  centimetres. 


74  DISEASES   OF   THE   NERVOUS   SYSTEM. 

A  formula  for  applying  electricity  may  be  written  thus : 

Anod.  galvanization,  10  ma.  5  X 15  cm.  daily,  5'  stabile. 

This  means  that  the  positive  pole  of  the  galvanic  current  is  to 
be  applied  steadily  at  a  given  place  daily  for  five  minutes  with  an 
electrode  of  75  square  centimetres. 

The  terms  "  ascending"  and  "  descending  currents"  are  rarely 
used,  the  name  of  the  pole  being  employed  instead.  Thus,  anodal  gal- 
vanization of  the  brain  or  arm  means  that  the  positive  pole  is  applied 
at  these  localities.  With  the  faradic  and  static  currents,  neither 
the  pole  nor  the  direction  of  the  current  makes  much  difference. 

Electro-Diagnosis. — When  a  motor  nerve  is  cut  off  from  its  centre 
in  the  spinal  cord,  or  when  this  centre  itself  is  diseased,  the  nerve 
and  later  the  muscle  undergo  a  degeneration.  As  a  result  of  this, 
their  reaction  to  electrical  currents  is  changed,  and  we  get  what  is 
termed  "partial  degeneration  reactions"  and  "  complete  degeneration 
reactions,"  according  to  the  degree  of  disturbance.  These  reactions 
are  due  mainly,  if  not  wholly,  to  the  degeneration  in  the  terminal 
nerve  fibres  and  motor  end  plates  in  the  muscle.  When  the  muscle 
alone  is  diseased,  the  reaction  is  not  changed  until  very  late.  The 
change  in  irritability  is  due  to  the  fact  that  as  the  nerve  fibre  wastes 
it  takes  an  electric  current  of  comparatively  long  duration  and  con- 
siderable strength  to  stimulate  it. 

The  first  effect  is  to  cause  it  to  lose  its  contractility  or  reaction 
to  weak  currents,  then  to  extremely  rapid,  short  currents  like  the 
static,  then  to  the  faradic,  and  last  to  the  galvanic.  Such  change  is 
known  as  the  quantitative  alteration  in  electric  irritability. 

But  besides  this,  the  nerve  and  muscle  are  affected  in  a  different 
way  by  the  different  poles  of  the  galvanic  battery.  In  normal  nerve 
and  muscle,  a  contraction  is  caused  more  readily  by  the  negative 
pole  than  by  the  positive.  But  muscles  with  degenerated  nerve 
supply  sometimes  respond  as  well  or  better  to  the  positive  pole. 
This  forms  what  is  called  the  qualitative  or  serial  change  in  the  irri- 
tability of  the  muscle. 

Finally,  degenerated  muscles  respond  more  sluggishly  than 
normal  to  the  galvanic  and  faradic  currents.  The  contraction,  in- 
stead of  being  sharp  and  jerky,  is  sluggish  and  almost  tetanic. 
This  is  called  the  modal  change  in  irritability,  and  it  is  far  the  most 
important  sign  of  muscular  degeneration. 

The  qualitative  change  is  gotten  only  by  placing  the  active  elec- 
trode over  the  muscle,  but  the  quantitative  and  modal  changes  may 
be  gotten  by  placing  the  electrode  over  the  nerve  as  well  as  over  the 
muscle.  In  describing  these  changes,  the  following  abbreviations 
are  used : 


HYGIENE,    PROPHYLAXIS,    TREATMENT. 


75 


DeR  =  degeneration  reaction. 

AnCC  =  anode  or  positive-pole  closure  contraction. 
CaCG  =  cathode  or  negative-pole  closure  contraction. 
AnOG  =  anode  opening  contraction. 
CaOG  =  cathode  opening  contraction. 
Te  =  tetanus. 

D  =  circuit  is  closed  and  current  flowing. 

AnDTe  =  tetanic  contraction  while  the  positive  pole  is  applied 
and  the  circuit  closed. 

The  sign  >  means  greater  than;    <,  less  than.     Thus  AnCC> 


Fig.  4~'. 

CaCG  means  anode   closure   contraction  is   greater    than   cathode 
closure  contraction. 

Degenerations  in  nerve  do  not  occur  except  in  lesions  of  the 
nerve  or  spinal  cord,  and  in  very  late  stages  of  primary  atrophy  of 
muscles.  Hence  when  one  finds  degenerative  reactions,  he  can 
almost  absolutely  exclude  disease  of  the  brain,  functional  disease, 
and  primary  disease  of  the  muscle.  The  following  rules  may  be 
formulated  for  testing  for  degeneration  reactions : 

Use  the  faradic  current  first. 

The  Faradio  Current. — Use  a  secondary  induction  coil  of  wire 
.225  mm.  in  diameter  and  800  metres  long.  The  distance  over  which 
the  coil  moves  is  divided  into  a  hundred  parts.  The  strength  of 
current  is  indicated  by  percentage  or  millimetres.  In  many  scales 
it  takes  ',)()  to  40  mm.  of  CD  or  coil  distance  to  cause  a  muscular 
contraction.      Record  the  minimum  necessary  for  muscular  contrac- 


76 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


tion,  using  the  same  electrodes  and  in  the  same  way  as  in  testing 
with  galvanism. 

The  Galvanic  Current. — 1.  Place  the  indifferent  pole  over  the 
sternum,  and  a  10  sq.  cm.  electrode  over  the  muscle.  2.  Pass  the 
current  for  one  minute.  3.  Then  find  the  minimum  strength  needed 
for  a  cathode  closure  contraction.  4.  Then  for  an  anode  closure 
contraction.  Repeat  this  test  three  times.  5.  With  a  given  cur- 
rent, note  whether  the  cathode  closure  contraction  is  stronger  than 
AnCC,  or  otherwise.  Test  this  three  times.  6.  Note  the  character 
of  the  contraction,  if  sharp  or  sluggish.     7.  Test  nerve  in  same  way. 

The  qualitative  changes  may  be  expressed  by  a  formula  like 
AnCC  =  or  >  CaCC,  i.e.,  the  positive-pole  closure  contraction  is 
equal  to  or  greater  than  the  negative-pole  closure  contraction.  Or, 
better,  the  minimum  strength  of  current  required  to  cause  a  con- 
traction in  the  muscle  is  recorded  for  the  positive  pole  and  for  the 
negative.     Thus : 

AnCC  5  ma.  or  8  cells. 
CaCC  4  ma.  or  6  cells. 

The  following  table  (modified  from  De  Watteville)  and  diagram 
(Fig.  42)  show  the  diseases  in  which  degeneration  reactions  may  be 
expected : 

Table   Showing   the   Lesion,    its  Results,    the    Names   op   the  Dis- 
eases, and  the  Electrical  Reactions. 


Lesion  of — 

Result. 

Disease. 

Electrical  Reaction  as  to 
Qualitative. 

1  to  2%. 

Paralysis,    con- 

Hemiplegia from  hemor- 

Nerve:  normal. 

Cortex  to  cord. 

tractures. 

rhage. 
Embolism,    tumors,    lat- 
eral sclerosis. 

Muscle :  normal. 

3,  4,  aud  5. 

Paralysis,    degen- 

Acute and  chronic  ante- 

Nerve: DeR. 

Coruua. 

erative  atrophy 
o  f    nerve  and 
muscle. 

rior  poliomyelitis. 

Muscle:  DeR. 

2  to  2]4. 

Paralysis,    con- 

Amyotrophic lateral  scle- 

Nerve :  normal    1  *-.  -p 
Muscle  :  partial  j  uetl' 

3  to  5. 

tractures. 

rosis. 

Lat.  cols,    and 

Degenerat  ive 

ant.  corn. 

atrophy  of  mus- 
cle. 
Degenerat  ive 

5  to  6. 

Progressive  muscular 

Nerve  :  normal. 

Trophic  cord 

atrophy  of  mus- 

atrophy (spinal  form), 

Muscle  :  or  partial  DeR. 

centres. 

cle. 

Paralysis     from 
wasting  of  mus- 
cle. 

Later,    degenera- 

bulbarparulysis (,?). 

When  disease  is  advanced. 

tion  of  nerve. 

Paralysis;  degen- 
erative atrophy 

Neuritis ;   from  wounds, 
toxaemia,  or  pressure. 

Muscle :  DeR. 

Nerve :  DeR. 

o  f    nerve  aud 

muscle. 

Muscle    

Wasting,  paresis. 

Simple  atrophy;  primary 

Nerve  and  muscle  normal 

or  idiopathic  myositis. 

until  late  iu  the  disease. 

Juvenile  form  of  progres- 

sive muscular  atrophy  ; 

pseudo-muscular  hyper- 

trophy ;  other  types  of 

primary  myopathies. 

Nerve  and  mus- 

Paresis and  atro- 

Rheumatic  atrophy  and 

No  DeR.  unless  severe. 

cle. 

phy. 

paresis. 

HYGIENE,  PROPHYLAXIS,  TREATMENT.  77 

It  should  be  said,  finally,  that  it  is  the  sluggish  contraction 
which  is  the  most  important  element  in  showing  degeneration :  also 
that  it  is  the  muscle  which  should  be  tested  most  carefully,  as  only 
over  it  does  one  get  the  qualitative  changes. 

Therapeutics.  — Electricity  is  used  as  a  counter-irritant  and  as  a 
general  mechanical  tonic  in  states  of  muscular  and  nervous  weak- 
ness. It  is  used  in  paralysis,  spasm,  and  pain,  and  for  its  supposed 
specific  action  in  certain  functional  and  organic  diseases. 

The  faradic  and  static  currents  have  a  counter-irritating,  stimu- 
lating, and  excito-reflex  effect.  The  galvanic  current  has  a  sedative 
and  antispasmodic  effect. 

Electrolytic,  cauterizing,  and  cataphoric  effects  are  also  pro- 
duced, but  are  rarely  needed  by  the  neurologist.  A  considerable 
portion  of  the  effects  of  electricity  are  psychical,  but  they  are  not 
the  less  real  or  valuable. 


CHAPTER   VII. 

GENERAL   DISEASES   OF    THE    PERIPHERAL    NERVES. 

Introduction — Anatomical.  — The  peripheral  nervous  system 
consists  of  twelve  pair  of  cranial  and  thirty-one  pair  of  spinal  nerves 
with  their  root  ganglia  and  terminal  sense  organs,  and  the  sympa- 
thetic nervous  system.  The  sympathetic  system  is  composed  of 
the  intervertebral  and  the  cranial  ganglia,  and  the  peripheral  gan- 
glia. The  latter  arise  during  embryonal  life  from  ganglionic  cells 
of  the  same  class  as  those  of  the  spinal  root  ganglia,  and  migrate 
to  their  adult  position  in  the  sympathetic  (Minot).  The  peripheral 
nervous  system,  therefore,  to  use  the  language  of  modern  anatomy, 
is  composed  of  peripheral  motor  neurons,  peripheral  sensory  neu- 
rons, and  peripheral  ganglionic  neurons  (Minot). 

The  Origin  of  Nerves. — The  recent  discoveries  of  the  true 
nature  of  the  nerve  cell  and  its  relation  to  the  nerve  fibre  have 
made  a  great  difference  in  our  conception  of  the  nervous  centres. 
We  now  know  that  the  peripheral  nerves  are  really  only  the  pro- 
longations of  the  axis-cylinder  processes  of  the  nerve  cells,  with 
certain  anatomical  additions  which  nature  has  made  in  order  to 
isolate  and  support  them.  The  peripheral  nerve  fibres  are  only 
a  part  of  certain  neurons.  The  motor  nerve  fibres  come  from  the 
motor  nerve  cells,  and  form  the  peripheral  part  of  the  peripheral 
motor  neurons.  The  sensory  fibres  are  derived  from  the  sensory 
nerve  cells,  and  are  only  a  part  of  the  sensory  neurons.  All  periph- 
eral nerve  fibres  of  motor  nerves  have,  in  the  spinal  cord  or  brain, 
certain  cells  of  origin,  which  are  known  as  the  nuclei  of  origin  of 
these  nerves.  These  motor  nuclei  lie  in  the  anterior  and  lateral 
horns  of  the  spinal  cord,  and  in  the  corresponding  parts  of  the 
medulla  and  pons.  It  has  been  customary  to  refer  the  sensory 
nerve  fibres  also  to  nuclei  of  origin  in  these  same  parts.  This, 
however,  according  to  modern  views,  is  not  correct.  All  sensory 
nerve  fibres  take  their  origin  from  nerve  cells  in  the  posterior 
nerve  ganglia,  or  in  corresponding  cranial  ganglia,  such  as  the 
petrous  and  the  jugular,  lying  upon  the  roots  of  the  cranial  nerves. 
The  nerve  cells  in  these  ganglia  send  off  a  single  process  which 
divides  in  a  T-shaped  fashion,  the  peripheral  branch  going  out  to 
form  the  sensory  fibre,  the  central  branch  passing  into  the  cord  or 
brain,  to  end  in  a  terminal  arborization  which  surrounds   groups 


GENERAL   DISEASES   OF   THE    PERIPHERAL   NERVES. 


79 


of  sensory  nerve  cells.  These  sensory  nerve  cells  in  the  cord  are, 
therefore,  not  really  nuclei  of  origin,  but  are  terminal  nuclei. 
There  are  no  nuclei  of  origin  for  sensory  nerves  in  the  central  ner- 
vous system.  This  changed  point  of  view  is  of  especial  importance 
in  our  consideration  of  the  anatomy  of  the  cranial  nerves  (Fig.  43). 

General  Pathology. 

Hyperemia  and  An.emia.—  Under  the  head  of  hypersemia  and 
anaemia  there  occur  types  of  nerve  irritation,  leading  to  different 
forms  of  neuralgia,  paraesthesia,  and  motor  weakness  or  irritation. 
Hypersemia  and  anaemia  are,  however,  secondary  conditions  and  are 
rarely   recognized   clinically.       It   cannot    always    be    determined 


Fig.  43.— Showing  the  Cells  of  Origin  op  the  Motor  Nerves  in  the  Anterior 
Horns  op  the  Spinal,  Cord,  and  the  Cells  of  Origin  of  the  Sensory  Nerves  in  thk 
Posterior  Spinal  Ganglia  (Van  Gehuchten). 

whether  an  irritated  nerve  is  congested  or  anaemic,  or  whether  the 
central  part  of  the  nervous  system  is  not  mainly  at  fault. 

Inflammation  of  Nerves — Neubitis. — There  are  two  forms 
of  neuritis:  1.  Interstitial  neuritis  and  perineuritis.  2.  Diffuse 
neuritis  with  parenchymatous  degeneration.  The  first  form  may  be 
acute  or  chronic. 

In  the  first  type  there  is  hypersemia,  with  sometimes  extrav- 
asation of  blood.  An  exudation  occurs  into  the  fibrous  frame  work 
of  the  nerve,  with  migration  of  leucocytes.  The  inflammation  may 
become  suppurative  or  gangrenous.  If  severe,  it  destroys  the  nerve 
fibres;  but  oftenest  the  axis  cylinders  are  not  destroyed,  and  re- 
covery takes  place.  Chronic  interstitial  neuritis  and  perineuritis 
are  accompanied  with  hyperplasia  of  the  connective  tissue,  compres- 
sion and  more  or  less  destruction  of  the  nerve  (Fig.  44).     It  may 


80 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


ascend  or  descend,  and  it  is  called,  accordingly,  ascending,  descend- 
ing, or  migrating  neuritis.  It  may  affect  only  certain  segments  of 
the  nerve,  when  it  is  called  segmental  neuritis  or  disseminated  neu- 
ritis. Tuberculous  and  syphilitic  neuritis  are  of  the  chronic  inter- 
stitial or  diffuse  type.  These  latter  forms  rarely  involve  peripheral 
nerves,  but  rather  the  intracranial  parts  of  the  cranial  nerves  and 
the  spiual  nerve  roots  in  meningeal  tuberculosis  or  syphilis.  A 
syphilitic  peripheral  multiple  neuritis  is,  however,  thought  to  occur 
sometimes.     Leprous  neuritis  is  a  very  typical  form  of  proliferating 


Fig.  44.— Acute  Infectious  Neuritis,  showing  hemorrhage,  connective-tissue  prolifera- 
tion, diseased  nerve  fibres,  and  obliterated  vessel  (Rosenheim). 

chronic  perineuritis.  Cancerous  neuritis  sometimes  occurs,  and  it 
is  of  the  diffuse  type,  though  sometimes  an  actual  cancerous  process 
invades  the  nerve. 

The  second  type  is  called  degenerative  neuritis  and  this  process 
of  degeneration  is  the  dominant  one,  so  that  the  changes  can  be  best 
described  under  the  head  of  degeneration  of  nerves : 

Degeneration  of  Nerves. — This  is  a  process  in  which  the 
nerve  fibres  gradually  die;  the  myelin  sheath  and  axis  cylinder 
disappear,  leaving  only  a  strand  of  connective  tissue. 

Nerve  Degeneration. — There  are  three  forms  of  nerve  degenera- 
tion: 1.  Primary,  2.   Secondary;  3.  Neuritic  or  toxic. 


GENERAL    DISEASES    OF   THE    PERIPHERAL   NERVES.  81 

1.  The  primary  form  is  rare,  slight  in  extent,  and  of  little 
clinical  significance.  In  it  there  is  simply  a  gradual  wasting  and 
disappearance  of  the  axis  cylinder  and  myelin  sheath.  It  occurs  in 
old  age,  wasting  diseases,  and  as  part  of  locomotor  ataxia  (Fig.  45). 

2.  Secondary  degeneration  or  YVallerian  degeneration.  This 
form  occurs  when  the  nerve  is  cut  across,  or  compressed,  or  de- 
stroyed by  inflammation,  neoplasms,  or  injuries. 

The  essential  part  of  the  nerve  fibre,  the  axis  cylinder,  is  simply 
a  prolongation  of  the  process  of  a  nerve  cell.  Its  next  essential  part 
is  the  myelin  sheath.  This  is  of  epiblastic  origin  and  consists  of  a 
hollow  cylinder  inclosed  in  a  thin  membrane  and  containing  a  fatty 
substance.  In  degenerative  processes  of  peripheral  nerves  the 
medullary  sheath  is  first  affected,  then  the  axis  cylinder,  least  and 


Fig.  45.— Simple  Atrophy  op  Nerve  in  Marasmus. 

last  the  neurilemma.  The  myelin  becomes  turbid,  splits  up  into 
fragments  and  droplets.  The  axis  cylinder  also  breaks  up  into 
fragments  or  swells  up  and  becomes  liquefied.  Extravasated  leu- 
cocytes pick  up  the  products  of  disintegration  and  form  fat-granule 
cells.  The  neurilemma  and  its  nuclei  usually  remain  intact.  The 
nerve  during  this  time  shrinks  in  volume  and  looks  grayish  and 
translucent,  or  grayish-red.  The  nerve  finally  become  only  a  fibrous 
cord.  Changes  can  be  seen  in  the  nerve  within  forty-eight  hours, 
and  by  this  time  its  irritability,  which  was  first  slightly  increased, 
is  lost.  In  about  two  weeks  the  disintegration  <>f  the  myelin  sheath 
and  axis  is  practically  complete  (Fig.  40) .  The  peripheral  end  of  the 
cut  nerve  shows  a  loss  of  nearly  but  not  quite  all  the  fibres  as  far  as 
its  termination.  In  the  central  end,  the  degeneration  ascends  at 
first  only  to  the  first  or  second  node  of  Etanvier.  Very  soon,  how- 
ever, a  change  occurs  in  the  cell  from  which  the  fibre  springs. 
This  change  is  called  the  reaction  at  >>  distance,  or  degeneration  of 


82 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


Nissl.  Thus  when  the  neuraxon  is  injured  the  whole  neuron  suf- 
fers, but  the  peripheral  eud  far  the  most. 

When  a  section  is  made  between  the  spinal  ganglia  and  the 
cord,  the  fibres  all  degenerate  toward  the  cord,  and  even  within  it, 
but  the  peripheral  fibres  do  not  degenerate.  Hence  the  spinal  gan- 
glia are  the  trophic  centres  of  the  sensory  nerves  (see  Fig.  47). 

Degeneration  occurs  in  the  motor  nerves,  also,  when  the  cells  of 
the  anterior  horns  are  destroyed.  Hence  these  cells  are  the  trophic 
centres  for  all  motor  nerves.  The  process  of  degeneration  takes 
place  at  about  the  same  time  throughout  the  whole  length  of  the 
nerve.  The  motor  end  plates  in  the  muscles  are  affected  a  little 
the  earliest.     About  the  cut  end,  little  bulbous   tumors   may  de- 


Fig.  46.- 


-Showing  Different  Stages  in  the  Process  of  Nerve  Degeneration  on  Sec- 
ond, Third,  Sixth,  and  Ninetieth  Days  after  Section  (Ranvier). 


velop,  which  contain  numerous  nerve  fibrils  and  connective  tissue. 
The  general  law  is  that  nerves  degenerate  in  the  direction  in  which 
they  carry  impulses,  but  this  is  not  the  whole  case,  as  has  been  just 
described.  If  the  injury  to  the  nerve  is  permanent,  a  slow  decay 
affects  the  whole  neuron.  Supposing  for  example  a  motor  nerve 
is  injured  or  inflamed  at  the  point  D.  Immediately  a  degenera- 
tion takes  place  along  the  parts  below  to  T,  and  in  a  few  days  a 
slight  degeneration  takes  place  in  the  cell  body  C  (see  Fig.  48). 

Summary:  Peripheral  nerve  fibres  degenerate  when  cut  off  from 
their  trophic  cells.  The  degeneration  begins  at  once  throughout 
the  length  of  the  nerve.  Loss  of  function  occurs  in  forty-eight 
hours.  The  degeneration  is  practically  complete  within  two  or 
three  weeks.  The  myelin  sheath  and  its  nuclei  are  affected  first, 
the  axis  cylinder  next.  The  degeneration  takes  place  most  quickly 
and  markedly  in  the  direction  in  which  the  nerve  impulse  runs, 
except  in  peripheral  afferent  nerves.     The  central  end  of  the  nerve 


GENERAL   DISEASES    OF   THE    PERIPHERAL   NERVES. 


83 


and  its  cells  of  origin  undergo  a  slower  and  milder  degeneration. 
The  final  stage  is  one  of  nerve  atrophy  or  of  nerve  degeneration. 

Within  the  central  nervous  system  degeneration  also  occurs  mainly 
in  the  direction  of  the  nerve  impulse.  The  axis  cylinder  is  first 
affected.  There  is  sometimes  a  preliminary  swelling  or  hypertrophy 
of  this  axis  cylinder.     Degeneration  with  calcification  of  the  nerve 

MR- 


Fig.  47.  —Showing  Effects  of  Section  of  Mixed  Nerves  and  Sensory  Root.    PMX. ,  Sec- 
tion through  mixed  nerve  ;  MR.,  motor  root;  S.R. ,  sensory  root;  S.G.,  spinal  ganglion. 

fibres  sometimes  occurs.  In  associative  or  commissural  fibres  the 
degeneration  extends  only  part  of  the-  length  of  the  nerve. 

3.  Xeuritic  or  toxic  nerve  degeneration.  This  form  occurs  in 
connection  with  neuritis,  and  will  be  described  under  that  head. 
Its  chief  characteristics  are  that  the  degeneration  attacks  the  nerve 
in  segments,  that  the  axis  cylinders  are  not  so  much  affected,  and 
the  myelin  breaks  up  into  small  fatty  droplets  instead  of  into  large 
masses.  The  same  general  laws  apply  to  it  as  to  Wallerian  degen- 
eration. 

Degenerative  processes  in  the  non-medullated  nervous  fibres  have 
been  observed  in  the  fine  fibres  of  the  cornea  and  in  the  submucous 
and  myenteric  plexuses  of  the  alimentary  tract. 

Regeneration  of  nerves  is  a  process  that  usually  follows  degen- 
eration.    It  occurs  only  in  peripheral  nerves — very  little,  if  at  all, 


Flo.  48. 

in  the  nerves  of  the  central  nervous  system  of  mammals.  It  is  an 
unique  process,  in  that  the  nerve  is  the  only  specialized  tissue  that 
can  grow  again  after  being  destroyed.  Regeneration  occurs  when- 
ever the  trophic  centres  are  healthy,  when  the  mechanical  obstacles 
to  a  union  of  the  divided  fibre  are  not  too  great,  and  when  the 
peripheral  nerve  is  not  too  completely  atrophied.  It  occurs  most 
quickly,  therefore,  when  the  cut  ends  are  carefully  apposed  and 
when  the  separation  has  not  lasted  for  a  long  time,  i.e.,  for  years. 


84 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


It  progresses  always  from  the  central  end  toward  the  periphery. 
The  fibres  of  the  central  stump  grow  out  into  the  degenerated  peri- 
pheral fibre.  Union  by  first  intention  or  second  intention  never 
occurs.  Human  nerves  cannot  be  made  to  unite  physiologically, 
but  only  anatomically. 

Regeneration  may  be  complete  in  a  few  months  in  short  nerves. 
In  the  sciatic  it  may  take  one  or  two  years.  When  regeneration 
takes  place,  the  axis  cylinders  of  the  central  stump  swell  and  divide 
into  a  number  of  new  cylinders  which  pierce  or  creep  around  the 
intervening  tissue,  enter  in  bundles  the  peripheral  nerve,  and  be- 
come inclosed  in  new  myelin  sheaths  and  neurilemma. 

General  Symptoms. 

One  of  the  commonest  forms  of  symptoms  occurring  in  the 
distribution  of  the  peripheral  nerves  is  paralysis  and  atrophy  of 
muscles  in  a  greater  or  less  degree.  But  since  the  motor  nerve 
carries  with   it   some  vasomotor  and   secretory  fibres,   there  may 


Fig.  49. 


also  be  congestion,  oedema,  sweating,  etc.  When  the  motor  neuron 
is  damaged  only  to  a  moderate  extent  or  is  irritated  by  any  agent, 
twitchings  and  spasmodic  movements  of  the  muscle  may  occur. 
Spasmodic  symptoms  in  the  distribution  of  peripheral  nerves  may 
also  be  due  to  disturbances  acting  upon  the  central  motor  cell.  The 
seat  of  the  trouble  is  either  in  the  sensory  neuron,  as  in  reflex 
spasmodic  troubles,  or  in  higher  motor  neurons.  Thus,  in  a  spas- 
modic disorder  affecting  the  motor  nerve  A,  the  irritation  may  fee  in 
the  cell  body  C,  but  is  more  often  reflex,  starting  in  the  sensory 
neuron  S  or  in  a  higher  motor  neuron  whose  neuraxon  is  repre- 
sented at  P  (Fig.  49). 

A  symptom  that  is  also  very  common  in  disease  of  the  peripheral 
nerves  is  neuralgia,  or  the  milder  degree  of  nerve  irritation  called 
paresthesia.  We  have  besides  this  various  forms  of  anaesthesia, 
which  is  due  to  cutting  off  the  sensory  fibre  wholly.  Neuralgia  in 
its  simpler  and  commoner  pathological  forms  is  due  to  some  irrita- 
tion of  the  peripheral  sensory  neuron,  especially  its  ganglionic 
centre.     The  particular  nerve  affected  tells  the  location  of  the  irri- 


GEXERAL   DISEASES    OF   THE    PERIPHERAL    NERVES.  85 

tation.  But  the  peripheral  sensory  neuron  is  in  close  relation  with 
the  central  neurons  that  carry  the  painful  impressions  to  the  brain. 
Hence  the  whole  sensory  path  may  become  disordered,  and  this  is 
particularly  the  case  in  young  and  neurotic  patients.  As  a  conse- 
quence we  find  that  neuralgias  and  pains  are  more  diffuse  and  less 
sharply  localized  at  this  period  of  life.  Besides  this,  if  sometimes 
happens  that  the  central  sensory  neurons  in  the  brain  are  themselves 
the  seat  of  injury  or  irritation,  and  we  have  at  times,  therefore, 
central  neuralgias.  However,  there  can  be  no  doubt  that  the  central 
sensory  neurons  are  not  easiiy  irritated  to  the  point  of  exciting  pain 
referred  to  a  peripheral  nerve,  and  this  is  because  the  ascending 
sensory  tract  is  a  widely  diffused  one  and  not  massed  in  a  single 
compact  fasciculus. 

It  will  be  seen  from  the  foregoing  that  the  nervous  diseases 
affecting  the  functions  of  the  peripheral  nerves  will  fall  into  three 
classes:  first,  those  affecting  a  large  part  of  the  spinal  nerves,  at  the 
same  time  causing  general  symptoms  of  paralysis,  pain,  etc. ;  next, 
diseases  involving  especially  certain  nerves  of  motion;  and  finally, 
those  affecting  especially  nerves  of  sensation.  So  I  shall  describe 
general  neuroses  involving  the  functions  of  many  and  mixed  nerves, 
then  neuroses  in  the  limits  of  the  motor,  and  those  in  the  distribu- 
tion of  sensory  nerves. 

MULTIPLE  NEURITIS— POLYNEURITIS. 

I  Iriginally  multiple  neuritis  was  described  as  though  it  were  al- 
ways the  same  disease.  Later  investigations  show  that  this  is  not 
a  true  view  to  take  of  it  because  nerves  are  inflamed  in  very  differ- 
ent ways  and  degrees,  and  because  the  causes  of  the  inflammation 
affect  the  general  system  so  differently.  A  diagnosis  of  multiple 
neuritis  alone  is,  therefore,  not  sufficient.  The  chief  recognizable 
forms  of  multiple  neuritis  are:  1.  The  motor  form,  or  paralytic 
neuritis.  2.  The  sensory  or  ataxic  form  of  neuritis  (pseudotabes). 
.'».  Kndemic  neuritis  (beriberi).  4.  Acute  pernicious  neuritis  (Lan- 
dry's paralysis).* 

The  Motob  Type  of  Multiple  Neuritis  (Alcoholic  /'"- 
ralyaiSf  Arsenical  Paralysis,  Diphtheritic  Paralysis). — This  is  the 
common  form  of  the  disease,  making  up  fully  ninety  per  cent  of  all 

*  Among  71  cases  of  multiple  neuritis  of  which  I  have  analyzed  the  notes 
there  wen;  of  the  common  motor  form,  62;  sensory  or  pseudotabetic,  4 ; 
endemic  (beriberi),  3;  acute  pernicious,  2. 

Over  half  of  the  motor  type  were  confessedly  alcoholic,  34.  Of  the  others, 
there  were  :    Post-diphtheritic,  8  ;  measles,  1  ;  grippe,  2  ;  erysipelas,  1 ;  sepsis, 


86  DISEASES    OF    THE    NERVOUS   SYSTEM. 

cases  seen  in  this  country.  While  sensory  and  other  symptoms  al- 
ways accompany  this  type,  it  is  the  paralysis  and  atrophy  of  mus- 
cles which  are  the  leading  and  chronic  conditions.  It  is  a  malady 
coming  on  acutely,  running  a  subacute  or  chronic  course,  rarely 
fatal,  and  characterized  by  weakness  or  paralysis  of  all  four  ex- 
tremities associated  with  atrophy,  pain,  tenderness,  and  various 
vasomotor,  secretory,  and  trophic  disturbances.  It  is  a  disease 
pre-eminently  due  to  poisons  and  infections,  alcohol  being  far  the 
commonest  factor. 

It  occurs  oftener  in  the  female,  owing  to  the  fact  that  alcohol 
poisons  the  nerves  of  women  more  than  of  men,  and  perhaps  because 
of  the  predisposing  influence  of  tea-drinking. 

Multiple  neuritis  is  essentially  a  disease  of  early  adult  life.  Al- 
most all  cases  occur  between  adolescence  and  the  period  of  degenera- 
tive changes,  twenty  to  forty-five.  Young  children  are  very  rarely 
subject  to  it,  but  cases  have  been  reported  occurring  in  children  at 
the  age  of  seven,  nine,  ten,  and  fourteen,  and  G.  M.  Hammond  has 
reported  several  cases  occurring  in  infants.  A  few  cases  have  oc- 
curred in  persons  over  sixty ;  but  they  are  only  a  little  less  suscep- 
tible than  children. 

The  sporadic  forms  of  polyneuritis  from  alcohol  and  various 
poisons  and  infections  occur  without  much  reference  to  a  seasonal 
influence.  Probably  more  cases  occur  in  spring  and  fall,  owing  to 
sudden  changes  in  temperature.  Epidemic  influences  like  that 
causing  cerebro-spinal  meningitis  may  increase  the  number  of  cases 
of  multiple  neuritis.  Practically,  in  this  country,  the  question  of 
drink  settles  the  question  of  the  distribution  of  polyneuritis.  It  is 
rare  in  the  temperate  rural  districts  and  smaller  towns,  and  much 
rarer  in  native  Americans  than  in  foreigners. 

Sexual  excesses,  exposure  to  cold  and  wet,  insufficient  diet,  ex- 
cessive tea-drinking,  the  presence  of  tuberculosis,  predispose  to  the 
disease.  The  same  neuropathic  tendency  leading  persons  to  excesses 
in  alcohol,  tea,  and  to  suicidal  indulgence  in  arsenic  is  of  some 
moment  in  leading  to  the  development  of  neuritis. 

The  list  of  the  special  and  exciting  causes  is  long  and  includes 
nearly  all  infections  fevers,  many  chemical  and  autochthonous 
poisons.      The  common  infections  are  diphtheria,    puerperal  and 

1;  puerperium,  4;  diabetes,  2 ;  metallic  poison  (lead),  2;  ptomaine  poison- 
ing, 1. 

The  sex  of  44  was  male,  27  female,  but  in  the  alcoholic  cases  the  sex  was 
female  in  the  proportion  of  10  to  1. 

The  age  ranged  from  under  10  (diphtheritic  cases)  to  67.  Most  cases  oc- 
•  curred  between  31  and  40  (25  cases),  next  between  21  and  30  (18),  and  next 
between  41  and  50  (15) . 


GENERAL    DISEASES    OF    THE    PERIPHERAL    NERVES. 


87 


other  septic  fevers,    and    endemic   infections  of   unknown  origin. 
Nearly  every  infectious  fever  and  malaria  may  be  added  to  the  list. 

Of  chemical  poisons  alcohol  heads  the  list,  causing  over  two- 
thirds  of  the  adult  cases.  Next  come  arsenic,  lead  and  phosphorus, 
and  copper.  Among  the  autochthonous  poisons,  rheuniatisms  dia- 
betes, and  the  metabolic  products 
resulting  from  starvation  and  ca- 
chexia lead  to  multiple  neuritis.* 

Among  the  foregoing  causes, 
arsenic  and  diabetes  produce  more 
often  decided  sensory  symptoms. 

Prodromata.  —  The  disease 
often  begins  with  prodromata 
lasting  several  weeks.  The  pa- 
tient suffers  from  numbness, 
slight  pains,  and  weakness  affect- 
ing especially  the  lower  extrem- 
ities. Sometimes  a  peculiar 
condition  of  mental  confusion 
and  weakness  precedes  the  attack. 
Usually  the  symptoms  come  on 
rather  suddenly.  The  patient 
suffers  from  pains  and  tenderness 
in  the  legs  and  feet,  and  is 
obliged  to  go  to  bed.  There  may 
be  a  fever  for  a  day  or  two,  the 
temperature  rising  to  102°  or 
even  104°  F.,  but  this  is  not  the 
rule.  The  pains  and  weakness 
increase.  The  m  u  s  c  1  e  s  and 
nerves  are  very  tender.  The  fin- 
ger8,  hands,  and  arms  are  often 
similarly  but  less  affected.  At 
the  same  time  the  skin  becomes  reddened  or  slightly  oedematous. 
The  muscles  of  the  legs  grow  weak,  and  in  a  day  or  two  the  patient 
is  unable  to  stand.  In  a  week  or  two  there  may  be  a  complete  loss, 
of  power  in  the  anterior  tibial  muscles  and  a  lesser  degr< 1  paraly- 
sis in  the  extensors  of  the  hand  (Fig.  5<h.  Nearly  all  cf  the  leg  and 
forearm  muscles  become  eventually  involved.  Atrophy  sets  in  at 
the  same  time  and  very  severe  pains  are  present.  The  motor  cranial 
nerves  are  in  rare  cases  affected,  and  paralysis  of  the  facial  or  of 
the  third,  fourth,  or  sixth  nerve  has  been  seen.  When  the  disease 
is  fully  developed,  which  is  within  a  fortnight,  there  is  paraplegia. 
•Trional  is  to  be  added  to  the  list  of  drugs  which  may  cause  neuritis. 


Fig. 


50.  —  Alcoholic  Paralysis,  with  Foot 
Drop  and  Wrist  Drop. 


88  DISEASES   OF   THE   NERVOUS    SYSTEM. 

with,  foot  drop,  some  degree  of  wrist  drop,  muscular  atrophy,  and 
slight  oedema,  especially  of  the  feet.  The  skin  reflexes  are  often, 
the  knee  jerk  and  elbow  jerk  always  lost.  There  is  some  tactile  an- 
aesthesia, often  with  hyperalgesia.  Temperature  and  pain  sense  are 
also  lessened  and  slowed  in  transmission.  The  anaesthesia  occurs 
in  patches  or  diffusely.  Muscle  and  articular  sense  are  lost  in  the 
sensory  or  pseudo-tabetic  form,  and  are  usually  somewhat  involved 
in  the  ordinary  paralytic  form.     Pain  and  sensitiveness  continue. 

The  nerves  lose  their  irritability  and  the  muscles  show  degenera- 
tion reaction,  partial  or  complete,  the  characteristic  being  a  great 
variability  of  reaction  over  different  groups  of  nerves  and  at  different 
stages  of  the  disease,  and  an  early  loss  of  faradic  and  lessening  of 
galvanic  irritability.  There  is  sometimes  retinal  hyperaemia  and 
even  optic  neuritis.  Of  the  visceral  nerves,  the  vagus  seems  often- 
est  to  show  signs  of  involvement,  in  rapid  pulse  and  disturbances  of 
respiration.  The  sphincters  are  rarely  involved  and  then  only  for  a 
few  days.  In  such  cases  there  is,  perhaps,  involvement  of  the  cord 
or  of  the  abdominal  and  pelvic  splanchnics.  In  alcoholic  and  occa- 
sionally in  other  forms  of  neuritis,  mental  symptoms,  such  as  a  low, 
muttering  delirium,  are  very  often  present,  and  occasionally  a  well- 
marked  confusional  insanity  develops. 

The  disease  usually  reaches  its  height  in  a  week  or  two  and  then 
starts  on  a  chronic  course;  but  it  sometimes  happens  that  exacerba- 
tions occur,  or  that  a  paralysis  and  atrophy  progress  for  several 
weeks  before  regression  begins.  In  alcoholic  cases  there  is  often 
great  general  prostration ;  the  patients  lie  for  several  weeks  in  a 
delirious  condition,  and  finally  develop  pneumonia  and  die. 

In  diphtheritic  neuritis  some  of  the  eye  and  throat  muscles  are 
involved,  while  the  extremities  are  usually  but  slightly  or  tempo- 
rarily affected  and  the  sensory  symptoms  are  few. 

Some  further  details  should  be  added. 

Motor  Symptoms. — The  characteristic  paralysis  of  multiple  neu- 
ritis is  a  quadruplegia,  all  four  extremities  being  involved.  The 
special  characteristic  is  the  foot  drop,  which  is  indicative  of 
alcoholic  neuritis,  just  as  wrist  drop  is  of  lead  palsy.  The  paraly- 
sis is  typically  a  peripheral  one.  It  affects  the  feet  and  legs,  hands 
and  forearms.  It  usually  involves  the  anterior  tibial  muscles  more 
than  the  calf  muscles,  but  sometimes  the  reverse  occurs.  The 
muscles  become  wasted  and  flabby.  They  soon  lose  in  bad  cases 
all  reaction  to  faradism,  and  they  require  a  strong  galvanic  current 
to  produce  a  contraction.  In  anterior  poliomyelitis,  on  the  other 
hand,  the  diminution  in  galvanic  irritability  comes  o\\  only  after 
weeks  or  months.     Hence  an  early  loss  of  galvanic  as  well  as  faradic 


GENERAL   DISEASES   OF   THE    PERIPHERAL  NERVES.  89 

reaction  is  an  important  sign  of  neuritis.  As  the  nerve  and  muscle 
recuperate,  the  galvanic  irritability  increases.  After  a  time,  if  the 
paralysis  is  great,  contractures  occur.  The  feet  are  extended,  the 
legs  are  flexed  on  the  thighs,  and  are  almost  immovable,  and  the 
patient's  condition  is  most  pitiable. 

Sensory  Symptoms. — Numbness,  hyperesthesia,  severe  pains 
(dull  and  sharp),  burning  sensations,  great  tenderness,  all  occur, 
and  are  very  marked  symptoms.  They  are  felt  mostly  in  the  feet, 
legs,  and  hands.  Hyperesthesia  is  usually  followed  by  anaesthesia 
to  touch  and  somewhat  to  pain  and  temperature.  The  transmission 
of  these  latter  two  sensations  is  delayed.  The  anaesthesia  some- 
times occcurs  in  patches,  at  other  times  diffusely  over  foot,  leg,  and 
hand.  Muscular  and  articular  anaesthesia  are  common,  and  in  the 
sensoiy  form  are  the  dominant  symptom,  causing  an  ataxia  of  gait 
and  station.  The  other  special  senses  are  not  affected  except  in 
rare  cases  in  which  there  is  optic  neuritis. 

Vasomotor  and  Trophic  Symptoms.  —  There  is  often  oedema,  some- 
times redness  of  the  skin;  occasionally  the  epidermis  of  the  soles 
and  palms  peels  off.  Glossy  skin  and  profuse  perspiration  are  rare. 
Eruptions  and  ulcers  do  not  occur. 

Mental  Symptoms. — The  most  common  mental  disturbance  is 
that  so  often  seen  in  acute  alcoholism,  viz.,  a  muttering  delirium. 
This  is  associated  with  great  general  vital  depression.  If  a  true 
insanity  develops,  it  also  resembles,  as  a  rule,  alcoholic  insanity  or 
acute  confusional  insanity.  The  characteristic  symptoms  are  a 
curious  degree  of  forgetfulness,  together  with  many  and  varying 
delusions  rapidly  succeeding  each  other.  These  often  relate  to  the 
pains  and  pallesthesia  from  which  the  subjects  suffer.  Tiny  think 
that  there  are  gloves  on  their  hands  or  that  something  is  on  their 
feet.  They  often  think  that  they  have  been  out  walking  or  riding. 
They  are  talkative,  incoherent,  and  sleepless. 

Organic  Centres. — The  bladder  is  occasionally  affected  for  a 
short  time,  the  other  centres  not  at  all.  This  freedom  from  involve- 
ment of  the  sphincters  is  an  important  characteristic  of  the  disease 
in  distinguishing  it  from  myelitis. 

From  the  foregoing  it  will  be  seen  that  the  dominant  symptoms 
are  pallesthesia,  pains  (burning,  lancinating,  and  dull),  muscular 
tenderness,  some  anaesthesia,  paralysis  affecting  especially  the  lower 
extremities  and  causing  foot  drop,  muscular  wasting,  with  degenera- 
tion reactions;  with  no  involvement  of  the  sphincters;  sometimes 
peculiar  mental  disturbances. 

THB  skxsoiiy  in;  PSEUDO-TABETIC  type,  of  multiple  neuritis  is 
caused  less  often  by  alcohol  and  more  often  relatively  by  diabetes 


90  DISEASES   OF   THE    NERVOUS   SYSTEM. 

and  the  metallic  and  infectious  poisons.  Arsenic  given  medicinally 
in  doses  of  one-sixth  of  a  grain  or  more  may  cause  such  a  neuritis. 
Multiple  neuritis  from  lead  is  not  often  seen  in  painters,  but  usually 
when  the  poison  is  taken  in  larger  doses,  as  in  snuff  takers.  The 
general  course  of  sensory  neuritis  is  much  like  that  of  the  paralytic 
form,  but  there  is  less  paralysis,  and  on  the  other  hand  there  are 
more  of  the  burning,  tearing  pains,  a  greater  degree  of  anaesthesia, 
with  a  very  decided  muscular  anaesthesia  causing  symptoms  of  a 
subacute  locomotor  ataxia.  The  paresis,  muscular  wasting,  trophic 
changes,  such  as  shedding  of  the  epidermis  and  electrical  reactions, 
serve  to  distinguish  the  disease.  A  double  facial  paralysis  some- 
times complicates  this  type. 

Endemic  and  Epidemic  Types  (Beriberi  or  Kakke,  Ljni- 
pedites,  Acrodynia,  Malarial  Multiple  Neuritis). — Beriberi  or  en- 
demic multiple  neuritis  is  seen  in  this  country  rarely,  and  only  by 
accident.  Beriberi  is  the  Indian  name;  kakke,  meaning  "the  leg 
disease,"  is  its  Japanese  name.  Ignipedites  is  a  name  given  by 
Indian  physicians  to  probably  the  same  disease.  French  physicians 
gave  the  name  of  "acroclynia"  to  an  epidemic  disease  which  pre- 
vailed in  France  and  the  Crimea  in  the  early  part  of  this  century. 
It  was  probably  multiple  neuritis.  There  are  various  types  of  this 
disease,  in  some  of  which  the  neuritic  symptoms  seem  subordinate 
to  those  of  other  organs.  The  forms  described  by  Scheube  and 
Taylor  are : 

The  acute  pernicious,  the  acute  or  subacute  benign,  the  atrophic 
or  dry,  and  the  dropsical  or  wet. 

The  symptoms  generally  resemble  those  of  multiple  neuritis,  as 
already  described,  plus  oedema,  extensive  serous  effusions,  and 
gastro-intestinal  disorders.  The  paralysis  affects  especially  the 
lower  extremities,  but  in  beriberi  there  seems  to  be  an  especial  ten- 
dency also  to  involvement  of  vasomotor  and  visceral  nerves.* 

Acute  Pernicious  Multiple  Neuritis. — There  is  a  form  of 
multiple  neuritis  which  comes  on  suddenly,  progresses  rapidly,  and 

*  Malarial  Multiple  Neuritis. — Jamaica  seems  to  be  the  only  place 
in  which  the  malarial  poison  produces  an  endemic  neuritic  paralysis 
(Strachan) ,  and  the  causation  in  these  cases  is  not  yet  demonstrated.  Dr 
Strachan's  description  of  the  symptoms  of  what  he  terms  malarial  peripheral 
neuritis  shows  it  to  be  quite  extensive,  often  involving  trunk  and  cranial 
nerves,  and  accompanied  by  much  pain  and  wasting.  Cramps  and  skin 
eruptions  are  often  noted,  complications  that  do  not  occur  in  the  ordinary 
types.  There  are  sporadic  forms  of  multiple  neuritis  occasionally  seen  iu 
this  country,  but  it  is  yet  to  be  proved  that  the  malarial  Plasmodium  can 
alone  cause  neuritis.  It  is  more  likely  that  it  acts  only  in  conjunction  with, 
some  other  toxic  condition. 


GENERAL   DISEASES   OF   THE    PEKIPHERAL   NERVES. 


91 


causes  death  in  a  few  days  or  weeks.  These  cases  usually  show  the 
ordinary  symptoms  of  neuritic  paralysis,  with  final  involvement  of 
the  cardiac  and  respiratory  nerves,  causing  death.  The  agent  iu 
these  cases  is  apparently  of  the  nature  of  sepsis.  The  neuritis  is 
interstitial  and  hemorrhagic.  Other  cases  of  acute  pernicious  mul- 
tiple neuritis  take  the  form  of  acute  ascending  or  Landry's  paraly- 
sis. Here  there  are  few  sensory  symptoms,  no  electrical  changes  or 
atrophy.     The  disease  is  due  to  an  infectious  poison  which  over- 


Ip^Pt 


/?l. 


Fig.  51.— Diphtheritic    Neuritis,    Chiefly    Interstitial    (Siemerling) ;    with 
secondary  degeneration. 


whelms  the  system  before  it  has  time  to  set  up  any  inflammation 
or  organic  change.  In  these  cases  the  anterior-horn  cells  of  the 
spinal  cord  are  also  involved  and  the  disease  is  one  that  attacks  the 
whole  peripheral  motor  neuron. 

Pathology. — In  multiple  neuritis  the  disease  affects  the  periphery 
of  the  nerves  most,  and  extends  up,  very  rarely  reaching  the  routs. 
The  anterior  tibial  and  musculo-spinil  nerves  on  the  two  sides  are 
oftenest  and  most  diseased.  The  process  when  mild  in  grade  re- 
sembles a  secondary  degeneration  following  section  of  the  nerve. 
In  severer  cases  there  is  evidence  of  interstitial  inflammation  as  well 


92 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


as  degeneration  (Fig.  51) .  This  process,  however,  varies  in  degree 
at  different  points  of  the  nerve' s  course.  Hence  it  has  been  called 
segmental  or  disseminated  neuritis.  In  some  of  these  cases  and  in 
all  acute  pernicious  cases  there  is  still  more  interstitial  inflamma- 
tory change;  small  hemorrhages  occur,  exudation  takes  place,  and 
collections  of  leucocytes  about  the  vessel  walls  and  among  the 
nerve  fibres  are  seen  (Fig.  52).  The  muscles  supplied  by  the  dis- 
eased nerves  undergo  atrophy.  This  is  usually  simple  and  non-in- 
flammatory. But  sometimes  there  is  an  interstitial  myositis  with 
exudation  compressing  the  fibres  (Senator). 

If  the  disease  progresses,  the  nerve  fibres  degenerate  and  their 


Fig.  52. — Longitudinal  Section  of  a  Nerve  in  Multiple  Neuritis,  showing  rich  prolifer- 
ation of  nuclei  (Leyden).    The  process  here  is  inflammatory  as  well  as  degenerative. 

place  is  taken  by  connective  tissue,  and  the  same  process  occurs  in 
the  muscles. 

The  spinal  cord  when  examined  by  the  help  of  JSTissl  and  Marchi 
stains  shows  some  involvement.  The  anterior-horn  cells  undergo 
the  same  degeneration  as  that  which  occurs  when  the  nerve  is  cut 
across,  and  slight  areas  of  degeneration  are  found  in  the  posterior 
and  lateral  columns.  The  changes  are  very  slight  compared  with 
those  in  the  nerves  and  in  the  writer's  opinion  are  secondary. 

It  will  be  seen,  therefore,  that  in  multiple  neuritis  there  may 
be:  (1)  Simple  degeneration;  (2)  degeneration  with  some  evidences 
of  interstitial  neuritis  (degenerative  neuritis)  ;  (3)  decided  intersti- 
tial neuritis  with  degeneration  of  nerve  fibres. 


GENERAL   DISEASES   OF   THE    PERIPHERAL   NERVES.  93 

Diagnosis. — Multiple  neuritis  must  be  diagnosticated  from 
diffuse  or  transverse  myelitis,  anterior  poliomyelitis,  locomotor 
ataxia,  spinal  meningitis,  and  hemorrhage  aud  Landry's  paralysis. 
Practically,  diffuse  myelitis  is  the  disorder  from  which  it  has  often- 
est  to  be  distinguished.  From  this  it  is  recognized,  first,  by  investi- 
gating the  cause  and  onset.  Neuritis  begins  more  slowly  and  with 
sensory  prodromata ;  it  affects  the  legs  and  feet,  especially  the  ex- 
tensors, and  if  it  ascends  it  skips  the  hips  and  trunk  and  attacks 
the  forearms.  There  is  more  muscular  atrophy  than  in  myelitis; 
the  knee  jerks  are  absent.  It  progresses  more  slowly,  and  after 
four  or  eight  weeks  gradually  regresses.  Electrical  degeneration 
reactions  are  more  varied  and  decided.  There  are  tenderness  over 
the  muscles  and  nerves  and  peculiar  burning,  darting  pains.  The 
cutaneous  anaesthesia,  if  present,  is  not  so  extensive  and  complete, 
as  a  rule,  while  muscular  anaesthesia  is  more  decidedly  marked. 
There  is  very  rarely  involvement  of  the  sphincters  or  bedsores. 
There  may  be  belt-like  constrictions  felt  round  the  extremities,  but 
not  around  the  waist.  The  gradual  improvement  of  the  paralysis 
and  atrophy  and  eventual  recovery  confirm  the  diagnosis  of  neuritis. 
The  presence  of  neuritis  of  the  cranial  nerves  would  strengthen  the 
theory  of  a  general  neuritis. 

From  poliomyelitis  it  is  distinguished  by  the  presence  of  pain  and 
other  sensory  symptoms,  the  early  fall  in  galvanic  irritability,  the 
age  of  the  patient,  and  the  etiology. 

From  locomotor  ataxia,  neuritis  is  distinguished  by  its  more  rapid 
onset,  the  presence  of  paralysis  and  atrophy  of  muscles,  paresis. 
with  degeneration  reactions,  and  the  absence  of  involvement  of  the 
organic  centres  and  pupils. 

Spinal  hemorrhage  usually  leads  soon  to  a  secondary  diffuse 
myelitis  easily  distinguishable  from  neuritis  by  the  characters  above 
given.  Here  there  is  also  usually  pain  in  the  back.  Spinal  menin- 
gitis is  associated  with  characteristic  pain,  tenderness,  and  stiffness 
along  the  back.  Acute  ascending  paralysis  in  its  typical  form  shows 
but  very  slight  sensory  disorders,  and  no  wasting  or  change  in 
trioal  irritability. 

The  complication  of  multiple  neuritis  aud  myelitis  or  posterior 
sclerosis  is  possible,  but  is  very  rare.  In  the  former  ease  the  ordi- 
nary symptoms  of  myelitis  are  added  to  those  of  neuritis.  In  loco- 
motor ataxia  there  is  often  some  nerve  degeneration  and  occasionally 
neuritis.  The  nerve  degeneration  probably  causes  only  slow  atrophia 
changes  and  paresis;  the  neuritis  causes  pains,  anaesthesia,  skin 
eruptions,  and  local  trophic  disorders. 

Prognosis Alcoholic  multiple  neuritis  is  a  serious  disease,  be- 


94  DISEASES    OF   THE   NERVOUS   SYSTEM. 

cause  of  its  associated  conditions.  Nearly  one-half  of  my  patients 
have  died,  mainly  because  they  continued  the  use  of  alcohol  after 
paralysis  appeared.  They  do  not  die  of  neuritis,  but  of  alcoholism 
or  of  phthisis.  Other  forms  of  neuritis  rarely  cause  death.  The 
great  majority  recover  almost  completely.  It  may  be  from  six 
months  to  two  years  before  all  symptoms  disappear.  The  average 
time  is  about  a  year. 

Treatment. — The  patient  needs,  first  of  all,  rest  in  bed.  The 
limbs  are  often  extremely  tender  and  the  patient's  pains  excruciat- 
ing. To  relieve  these  the  legs  may  be  painted  with  menthol  and 
enveloped  in  cotton  batting.  In  other  cases  flannels  wrung  out  in 
hot  water  and  renewed  every  two  hours  give  relief.  Internally 
phenacetin,  antipyrin,  or  other  coal-tar  products  may  be  given  for 
the  pains.  Fluid  extract  of  ergot  in  doses  of  3  i.  to  3  ii.  repeated  in 
three  hours  sometimes  relieves  pain.  In  the  early  stages,  salicylate 
of  soda  in  doses  of  gr.  xx.  every  two  or  three  hours  is  recommended. 
If  there  is  a  great  deal  of  depression  from  alcoholic  poisoning, 
strychnine,  gr.  -fe  q.  3  h.,  and  aromatic  spirits  of  ammonia,  3  ss. 
q.  3  h.,  should  be  used. 

There  is  no  drug  which  really  cuts  short  the  process.  The  best 
measures  for  this  purpose  are  rest,  thorough  cleansing  of  the  alimen- 
tary tract,  abstinence  from  alcohol,  and  a  nourishing  diet. 

After  the  acute  stage  is  passed  the  labile  galvanic  current  occa- 
sionally interrupted  may  be  applied,  5-  to  10  ma.  for  ten  minutes  three 
times  weekly.  Later,  by  the  sixth  week,  the  faradic  current,  mas- 
sage, and  careful  exercise  should  be  given.  At  this  time  or  earlier 
(third  Aveek),  strychnine,  iodide  of  potassium,  arsenic  in  small  doses, 
and  tonics  may  be  given.  In  old  cases  in  which  a  great  deal  of 
paralysis  and  contracture  have  occurred,  forcible  extension  of  the 
limbs,  the  use  of  splints  and  rubber  muscles,  are  needed.  With 
patience  and  perseverance  the  worst  cases  can  eventually  be  brought 
to  a  complete  recovery. 

Complicating  Forms  of  Neuritis  and  Neuritic  Degenera- 
tion.— Neuritis  and  neuritic  degeneration  complicate  many  dis- 
eases, but  they  especially  mark  and  modify  subacute  and  chronic 
rheumatism,  locomotor  ataxia,  diabetes,  paralysis  agitans,  wasting 
diseases,  and  old  age. 

A  neuritic  degeneration  almost  always  affects  the  nerves  in  the 
neighborhood  of  an  old  rheumatic  joint.  The  chief  result  of  this  is 
to  produce  wasting  and  some  paresis  of  the  muscles  moving  the  joint 
(Pitres  and  Vaillard).  The  process  is  a  reflex  atrophy  (see  Arthritic 
Muscular  Atrophy). 

In  locomotor  ataxia,  parenchymatous  nerve  degeneration  is  very 


GENERAL    DISEASES    OF   THE    PERIPHERAL    NERVES.  95 

often  present.  It  does  not  produce  the  cardinal  symptoms  of  this 
disease.  It  does,  however,  cause  some  of  the  anaesthesia,  pares- 
thesia, muscular  atrophy,  skin  dystrophies,  and  visceral  crises. 

In  diabetes,  the  neuritis  takes  the  form  of  the  sensory  type  of 
multiple  neuritis,  and  causes  symptoms  like  those  of  locomotor 
ataxia.  The  patient  has  sciatic  pains,  burning  or  numb  feet,  loss 
of  tendon  reflex,  ataxia.      The  upper  extremities  are  rarely  affected. 

In  Wasting  Diseases  and  Old  Age. — In  various  wasting  diseases, 
such  as  phthisis,  cancerous  cachexia,  long-continued  fevers,  maras- 
mus, and  in  senility,  a  simple  parenchymatous  degeneration  of 
nerves,  with  atrophy,  occurs  ( Arthaud,  Koster,  Jappa) .  The  symp- 
toms caused  by  these  changes  are  very  slight.  They  contribute  to 
the  weakness  and  wasting.  In  old  age,  the  atrophy  of  the  nerves 
is  one  cause  of  the  lessened  sensibility  and  activity  of  the  skin  and 
its  underlying  muscles. 

TUMORS  OF  NERVE. 

These  consist  of : 

1.  Nerve  hyperplasia. 

_  \  _.     ,  <  Benign. 

2.  True  neuromata.   { Single.  \  Mali       nt_ 

3.  False  neuromata,  j  Multiple.  {  Benign. 

1.  Hyperplasia  or  hypertrophy  of  nerve  trunks  is  very  rare. 
Generally  the  increase  in  size  is,  in  fact,  due  to  increase  of  the  in- 
terstitial connective  tissue.  Sometimes  there  is  an  increase  in  the 
number  of  fibres  and  thickening  of  the  myelin  sheath. 

2.  True  neuromata  are  also  very  rare,  and  occur  almost  exclu- 
sively on  spinal  nerves.  In  some  there  is  an  increase  in  medullary 
fibres;  in  others  only  an  increase  of  non-medullated  fibres,  i.e., 
only  the  axis  cylinders  and  neurilemma  increase.  They  occur 
either  singly  or  multiply.  Multiple  neuromata  are  generally  of  a 
neuro-fibromatous  character. 

Xcuro-fibromata  when  multiple  may  affect'  the  subcutaneous 
nerves  and  form  growths  known  &&  fibroma  molluscum. 

Nerve  fibres  united  in  a  mass  by  hyperplastic  connective  tissue 
form  what  are  called  plexiform  neuro-fibromata.  Multiple  neuro- 
mata may  be  true  neuromatous  growths. 

True  neuromata  are  usually  small,  ranging  from  1  cm.  (two 
fifths  of  an  inch)  to  6  cm.  in  diameter.  They  may  be  much  smaller 
or  larger.  Neuromata  are  usually  few  in  number,  or  at  least  there  io 
only  a  local  multiplicity  of  tumors.  Multiple  (true)  neuromata  ma>. 
however,  be  very  numerous.     Gowers  estimates  in  one  case  that  &Q 


96  DISEASES   OF   THE    NERVOUS    SYSTEM. 

many  as  one  thousand  were  present.     Even  larger  numbers  have 
been  observed. 

3.  False  Neuromata. — This  term  is  applied  to  the  various  nerve 
tumors  in  which  a  fibroma,  myxoma,  glioma,  sarcoma,  carcinoma, 
or  syphiloma  grows  upon  or  in  the  nerve.  Fibro-neuroma  is  tne 
most  common  form ;  glio-neuroma  has  been  observed  on  the  auditory 
nerve.  Syphiloma  occurs  only  on  the  intracranial  or  intraspinal 
nerves.  Carcinoma  of  nerves  may  be  primary,  but  is  generally 
secondary,  and  is  of  scirrhous  or  medullary  type,  rarely  the  colloid. 
Leprous  neuritis  sometimes  forms  neuro-fibromatous  swellings. 

Tubercula  dolorosa  are  simply  small  false  neuromata  situated 
subcutaneously  on  the  ends  of  the  sensory  nerves.  They  vary 
much  in  histological  structure. 

Malignant  Neuromata. — A  few  cases,  about  thirty  in  all,  have 
beeen  observed  of  multiple  malignant  neuromata.  Trauma  and 
hereditary  influence  are  the  etiological  factors.  The  great  nerve 
trunks  are  oftenest  affected,  the  median,  sciatic,  and  crural  ranking 
first.  The  tumors  start  from  the  perineurium;  they  are  at  first 
spindle  shaped,  and  may  grow  very  large.  Sarcomatous  cells  are 
oftenest  found  in  them;  but  they  may  be  myxomatous,  fibromatous, 
or  mixed. 

Etiology. — -Three  general  causes  exist  for  the  production  of  neu- 
romata, viz. :  1.  A  hereditary  or  a  neuropathic  predisposition;  this 
tends  to  cause  the  true,  the  multiple,  and  the  plexiform  neuromata. 
2.  Injuries,  surgical  operations ;  these  cause  especially  the  fibro- 
neuromata  of  which  the  amputation  neuroma,  is  an  example.  3. 
Diathetic,  e.g.,  tuberculous,  influences  and  whatever  produces  the 
various  tumor  formations,  sarcoma,  carcinoma,  form  the  third  etio- 
logical factor.  Neuromata  of  the  plexiform  type  are  often  con- 
genital. Multiple  neuromata  may  develop  early  in  life.  Men  are 
far  more  subject  to  multiple  neuromata  than  women. 

Si/nqrtoms. — Neuromata  often  cause  no  symptoms.  Perhaps  the 
most  frequent  evidence  of  their  presence,  however,  is  pain  and  some 
tenderness.  The  pain  is  exacerbating,  and  may  be  stopped  some- 
times by  pressure  on  the  nerve  above  the  tumor.  Paraesthesia, 
anaesthesia,  paralysis,  and  reflex  spasm  may  be  present.  Some 
forms  of  intractable  headache  are  possibly  due  to  multiple  neuro- 
mata. Multiple  and  plexiform  neuromata  cause  symptoms  less 
often  than  a  single  larger  neuroma.  A  neuroma  on  the  pneumo- 
gastric  or  other  splanchnic  nerve  may  cause  severe  symptoms. 
Multiple  (true)  neuromata  may  last  for  years  and  cause  no  serious 
inconvenience.  Malignant  neuromata  cause  always  such  symptoms 
as  would  naturally  follow  irritation  and  compression  of  a  nerve. 


GENERAL    DISEASES    OF   THE    PERIPHERAL    NERVES.  97 

The  diagnosis  of  neuroma  can  be  certainly  made  only  when  the 
tumor  can  be  felt.  In  other  cases,  by  exclusion  a  fairly  certain 
conclusion  may  be  reached. 

True  neuromata  are  often  multiple;  the  false  rarely.  Idiocy, 
heredity,  neuropathic  constitution,  scrofula,  would  all  favor  the  view 
of  the  disease  being  a  true  neuroma. 

The  treatment  is  essentially  surgical.  Internal  medication  and 
external  applications  are  of  little  value.  Strong  galvanic  currents, 
mercury,  and  the  iodides  in  large  doses  may  be  tried  in  true  neu- 
romata and  fibro-neuromata.  Both  true  and  false  neuromata  may 
return  after  extirpation. 
7 


CHAPTER   VIII. 

MOTOR  DISORDERS   OF   SPECIAL  NERVES. 

The  general  distribution  of  the  paralyses  from  injury  or  disease 
of  the  different  motor  nerves  is  shown  in  the  accompanying  table  of 
cases.  I  am  indebted  to  my  friend,  Dr.  Wm.  P.  Wilkin,  for  the 
larger  part  of  the  work  of  compilation : 

Cranial-nerve   paralyses  (including    19  occurring  in  locomotor 

ataxia) 92 

Spinal-nerve  paralyses 113 

Multiple  neuritis 68 

273 

Of  the  cranial  nerves  : 

Ocular  (third,  fourth,  sixth) 28 

Fifth 2 

Seventh     46 

Tenth  and  eleventh 4 

Of  the  spinal  nerves ; 

Arm 97 

Thigh  and  leg 16 

It  will  be  seen  that  the  brachial  plexus  and  its  branches  are 
oftenest  affected,  next  the  seventh  cranial  nerve,  then  the  ocular 
nerves,  and  last  the  lumbar  and  sacral  plexus.  This  of  course  repre- 
sents the  frequency  in  a  nurologist's  experience.  In  general  prac- 
tice and  especially  in  surgical  practice  there  would  be  fewer  cases 
of  cranial-nerve  disease  and  more  of  lumbar  and  sacral  palsies. 

The  Ocular  Muscles. 

Anatomy. — It  will  help  the  student  in  learning  the  diseases  of 
the  cranial  nerves  if  their  points  of  origin  and  general  relation  are 
shown,  as  in  the  accompanying  illustration  (Fig.  53). 

The  motor  nerves  of  the  eye  are : 

(a)  The  third  or  oculo-motorius,  supplying  the  internal,  superior, 
and  inferior  recti,  inferior  obliquus,  the  levator  palpebrae,  the  ciliary 
muscle,  and  constrictor  of  the  iris. 

(b)  The  fourth  or  trochlears,  suppyling  the  superior  oblique. 

(c)  The  sixth  or  abducens,  supplying  the  external  rectus. 

(d)  The  sympathetic,  consisting  of  fibres  from  the  upper  cervical 


MOTOR    DISORDERS    OF    SPECIAL   NERVES. 


99 


nerves  to  the  dilators  of  the  iris,  to  its  blood-vessels,  and  to  Midler's 
muscle. 

Motor  fibres  from  the  nucleus  belonging  to  the  third  nerve 
run  out  with  the  fibres  of  the  seventh  (Mendel),  supplying  the  orbic- 
ularis palpebrarum. 

The  third  and  fourth  nerves  arise  from  a  series  of  nuclei  in  the 
door  of  the  aqueduct  of  Sylvius.     They  leave  the  brain  at  the  an- 


Fig.  53.— Showing  the  Apparent  Origin  of  thu  Cranial  Nerves. 


terior  edge  of  the  pons.  They  run  in  the  cavernous  sinus  and  enter 
the  orbit  through  the  sphenoidal  fissure. 

The  sixth  nerve  arises  from  a  nucleus  in  the  floor  of  the  fourth 
ventricle.  It  emerges  at  the  posterior  edge  of  the  pons,  runs  in  the 
cavernous  sinus,  and  enters  the  orbit  through  the  anterior  lacerated 
foramen. 

The  nuclear  gray  matter  from  which  these  nerves  arise  is  made 


100 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


up  of  a  series  of  nests  of  cells  and  each  pair  supplies  a  different  set 
of  muscles  of  the  eye,  as  shown  in  the  diagrams  (Figs.  56  and  57). 

The  nucleus  of  the  sixth  lies  farther  back  in  the  floor  of  the 
medulla,  but  it  belongs  to  the  same  serial  deposit  of  gray  matter  and 
represents  the  continuation  of  the  anterior  horn  of  the  spinal  cord 
(Fig.  56). 

The  motor  nerves  of  the  eye,  third,  fourth,  and  sixth,  are  closely 
connected  with,  each  other  and  other  nerves  by  a  long  commissure, 
Hie  posterior  longitudinal  bundle. 

The  fibres  of  the  third  and  fourth  nerves  pass  to  their  nuclei  on 
the  same  side,  then  decussate  and  pass  up  in  the  inner  part  of  the 


Fig.  54.— Showing  Distribution  op  Third  and  Sixth  Cranial  Nerves. 

Crusta  to  the  frontal  part  of  the  central  convolutions  of  the  cortex, 
A  few  fibres  decussate  and  enter  the  nuclei  of  the  opposite  side. 
They  are  connected  with  the  internal  rectus  nucleus. 

The  fibres  of  the  fourth  nerve  almost  entirely  decussate,  running 
forward  a  long  distance  before  they  fmalty  reach  their  nuclei.  Thus 
it  appears  that,  the  fourth  is  the  only  cranial  nerve  except  the  optic 
which  largely  decussates  before  reaching  its  nucleus.  However, 
those  fibres  of  the  third  which  supply  the  internal  rectus  also  de- 
cussate, as  already  stated. 

The  arrangement  of  the  nuclei  is  believed  to  be  as  follows,  the 
upper  on  the  list  being  anterior : 

Median  line. 

r  Sphincter  iridis,  Ciliarius. 


III.  N. 


rv.  n.  \ 


Levator  palp. ,  Rect.  int. 
Rectus  superior,  Rect.  inf. 
Obliquus  inferior. 
Obliquus  superior. 


VI.  N.  -]  External  rectus. 


MOTOR    DISORDERS    OF    SPECIAL    NERVES. 


101 


In  order  to  understand  the  peculiarities  of  eye  palsies,  to  be  de- 
scribed later,  the  relations  of  the  sixth  to  that  nucleus  of  the  third 
nerve  which  innervates  the  internal  rectus  must  be  understood.  In 
turning  the  eyes  to  one  side,  these  two  nuclei  and  their  nerves  act 
together,  causing  the  external  rectus  of  one  eye  and  the  internal 
rectus  of  the  other  to  contract  at  the  same  time.  The  impulse  from 
the  brain  which  does  this  decussates  and  acts  first  upon  the  sixth, 
and  through  this  upon  the  external-rectus  nucleus  of  the  same  side. 
The  impulse  from  this  nucleus  then  goes  to  the  third-nerve  fibres  of 


V.  supratroch 
Ohl.  supe 


,V.  supraorb. 

j  Beet.  sup. 


ft.  in frobroch. 
Jtech  med. 


Ohl.  inf. 


Sect.  inf.  '    N.  supromax. 

Fig.  55.— The  Attachment  op  the  Eye  Muscles  to  the  Globe  (Merkel). 

the  same  side  and  thence  to  the  internal  rectus.  This  can  be  better 
understood  by  the  diagram,  Fig.  67. 

Thus  lesions  in  the  brain  at  («)  cause  paralysis  of  the  sixth 
nerve  of  the  opposite  side  and  internal  rectus  of  the  same  side. 
The  eyes  turn  toward  the  side  of  the  lesion. 

Lesions  in  the  pons  at  (//)  cause  paralysis  of  the  sixth  on  the 
same  side  and  internal-rectus  nucleus  of  the  opposite  side  The  eyes 
turn  away  from  the  side  of  the  lesion. 

The  eye  muscles  move  the  eyeball  in  the  following  way: 
The  superior  rectus  elevates  the  eyeball. 
The  inferior  oblique  rotates  out  and  up. 
The  inferior  rectus  depresses  the  eyeball. 
The  superior  oblique  rotates  out  and  down. 
The  superior  and  inferior  oblique,  acting  together,  rotate  inward. 
The  external  rectus  rotates  outward. 
The  internal  rectus  rotates  inward. 

The  rectus  internus,  rectus  superior,  obliquus  inferior,  rotate 
upward  and  inward. 


102 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


The  rectus  interims,  rectus  inferior,  obliquus  superior,  rotate 
downward  and  inward. 

The  rectus  externus,  rectus  superior,  obliquus  inferior,  rotate 
out  and  up. 

The  rectus  externus,  rectus  inferior,  obliquus  superior,  rotate 
out  and  down. 

The  movements  of  the  eyeball  are  made  by  the  simultaneous  ac- 
tion of  several  muscles.  Most  of  them  act  as  their  names  indicate. 
But  the  oblique  muscles  help  to  depress  and  elevate,  and  then  help  to 
rotate  in  or  out  according  as  the  internal  or  external  rectus  is  acting. 


OVTN 

Fig.  56.  Fig.  57. 

Fig.  56. — Diagram  showing  the  Arrangement  op  the  Nuclei  of  the  Motor  Nerves 
op  the  Eye,  and  the  Decussations  of  the  Fourth  and  Internal  Rectus  Branch  of 
the  Third  Nerve. 

Fig.  57. — Diagram  showing  the  Probable  Relations  of  the  Nuclei  of  the  Sixth 
and  of  the  Internal  Rectus  Branch  of  the  Third  to  the  Brain.  P.L.B.,  Posterior 
longitudinal  bundle. 

The  cortical  centres  for  the  eye  muscles  are  not  positively  known. 
Lesions  in  the  inferior  parietal  lobule  sometimes  cause  paralysis  of 
the  third  nerve.  Lesions  of  the  posterior  part  of  the  prefrontal 
lobes  also  sometimes  cause  eye  palsies,  especially  conjugate  devia- 
tion, and  the  dominant  are  in  the  prefrontal  lobe  at  the  base  of  the 
upper  and  middle  frontal  convolutions. 

As  the  optic  nerve  is  the  special  sensory  nerve  of  the  eye,  so  the 
third,  fourth,  sixth,  and  part  of  the  seventh  nerves  are  the  motor 
nerves.  By  means  of  the  optic  nerve  and  its  receptive  and  refrac- 
tive apparatus,  the  form,  color,  movement,  and,  to  some  extent,  re- 
lations and  distance  of  objects  are  determined.  The  motor  nerves 
adjust  the  eye  to  near  and  distant  objects,  inform  us  as  to  size  and 
distance,  and  enable  us  to  follow  moving  objects  and  to  shift  the 
gaze  readily.     They  also  assist  in  protecting  the  eye  against  injury. 


MOTOK    DISORDERS   OF   SPECIAL   NERVES.  103 

General  Symptoms. — It  is  impossible  always  to  disassociate 
diseases  of  the  oculo-motor  nerves  from  those  involving  their  nuclei. 
Hence  we  must  study  here  really  the  affections  of  the  whole  neu- 
rons.     These  are : 

1.  Paralyses  or  ophthalmoplegias,  which  may  be  acute,  chronic, 
or  progressive.  2.  Pareses  or  amyosthenic  states,  called  ordinarily 
muscular  asthenopias.  3.  Spasms,  such  as  strabismus,  nystagmus, 
and  blepharospasm. 

There  are  many  special  terms  which  are  used  to  indicate  the 
peculiar  effects  of  various  paralyses  and  spasms  of  the  ocular  muscles 
and  nerves,  and  some  of  these  I  will  define  here : 

Erroneous  projection  is  a  condition  in  which  the  patient  is  unable 
to  judge  exactly  of  the  relation  of  external  objects  to  the  body; 
for  this  relation  is  determined  by  the  movements  of  the  ocular 
muscles,  and,  these  being  weak,  wrong  sensations  are  conveyed  to 
the  brain.  Vertigo  may  result  from  this  disturbance  of  muscular 
sensation. 

Diplopia  or  double  vision  is  a  condition  due  to  the  erroneous  sen- 
sation resulting  from  eye-muscle  palsy,  and  to  the  fact  that  the 
images  of  the  object  fall  upon  non-corresponding  retinal  fields. 
Diplopia  is  simple  or  homonymous  when  the  false  image  is  seen  on 
the  same  side  as  the  affected  eye.  When  a  red  glass  is  placed  over 
this  eye  two  images  are  seen,  the  red  one  being  on  the  side  of  the 
eye  involved.  Diplopia  is  heteronymous  or  crossed  when  the  false 
image  is  on  the  side  opposite  to  the  sound  eye. 

Conjugate  deviation  of  the  eyes  is  a  condition  in  which  both  eyes 
turn  strongly  to  one  or  the  other  side.  It  may  be  paralytic  or  spas- 
modic. The  mechanism  is  a  complicated  one  and  not  perfectly  un- 
derstood. In  general,  destructive  lesions  of  the  brain  cause  a  para- 
lytic deviation  toward  the  side  of  the  lesion,  and  irritative  or 
compressing  lesions  the  opposite  effect.  Destructive  lesions  in  the 
pons  cause  a  deviation  away  from  the  side  of  the  lesions.  The 
palsy  then  involves  the  sixth  cranial  nerve  and  the  branch  to  the 
internal  rectus  from  the  third.  The  sixth-nerve  nucleus  is  the  domi- 
nant one,  and  impulses  from  the  brain  go  to  it  first  (see  Fig.  57). 

In  diseases  of  the  motor  nerves  of  the  eye  it  is  found  that  the 
paralyses  occur  in  various  ways,  which  may  be  best  grouped  as 
follows : 

Ophthalmoplegias . 

1.  Paralyses  of  the  third  nerve.  I  Acute. 

2.  Paralyses  of  the  fourth  and  sixth  nerves,  j  Chronic. 

3.  Progressive  paralysis  of  all  or  part  of  these  nerves. 


104  diseases  of  the  nervous  system. 

The  Ophthalmoplegias. 

I.  Paralysis  of  the  Oculo-Motorius  or  Third  Nerve— 
Etiology. — The  commonest  causes  are  exposure  to  cold,  and  syphilis. 
Other  causes  are  basal  meningitis,  intracranial  tumors,  injuries, 
compression  from  orbital  tumors,  the  diphtheritic  poison,  and  ex- 
cessive exposure  to  light ;  excessive  use  of  tobacco,  and  alcohol, 
morphine,  or  other  poisons  may  be  a  cause.  Temporary  palsy  some- 
times occurs  in  migraine,  or  it  may  take  the  place  of  an  attack  of 
migraine.  A  palsy  of  some  of  the  muscles  supplied  by  the  third  is 
sometimes  caused  by  cerebral  lesions  involving  the  inferior  parietal 
lobule.  Partial  palsies  also  occur  in  locomotor  ataxia  and  in  certain 
primary  muscular  atrophies.  The  common 
causes,  however,  are,  as  stated,  rheumatic  in- 
fluences and  syphilis. 

There  occurs,  in  rare  cases,  an  acute  in- 
flammatory degeneration  of  the  nuclei  of  the 
ocular- muscle  nerves  similar  to  acute  anterior 
poliomyelitis.  This  condition  has  been  called 
"  polio-encephalitis  superior"  or  upper  bulbar 
palsy. 

Symptoms. — When    all  the    muscles    sup- 

fig.  58. -Double  Ftosis;  Plied  by  the  third  nerve  are  paralyzed,  there  is 
dropping  of  the  lid  (ptosis,  Fig.  58);  the  eye 
can  be  moved  only  outward  and  downward  and  inward;  there  is 
therefore  divergent  strabismus  and  double  vision  (diplopia).  The 
pupil  is  somewhat  dilated  and  does  not  contract  to  light,  owing  to 
paralysis  of  the  constrictors  of  the  iris;  and  there  is  loss  of  power  of 
accommodation,  so  that  the  patient  cannot  read  print  close  to  him. 

The  patient  suffers  much  annoyance  from  the  lid  drop  and  the 
double  vision,  and  there  are  sometimes  vertigo  and  photophobia. 
Only  one  nerve  is  involved  at  a  time  as  a  rule.  The  various  eye 
muscles  supplied  by  the  third  are  rarely  all  attacked.  The  levator 
may  escape  almost  entirely ;  the  ciliary  muscle  and  iris  may  also  be 
but  slightly  involved;  but  these  latter  muscles  are  never  involved 
alone  in  ordinary  types  of  the  disease. 

The  affection  usually  runs  a  subacute  course,  lasting  but  a  few 
weeks.  Functional  palsies  last  but  a  few  days ;  syphilitic  palsies 
are  usually  temporary  (one  to  three  weeks),  but  may  relapse  or  be- 
come extremely  obstinate.  Periodical  palsies  occur  every  year  or 
six  months  or  even  oftener;  they  last  a  few  days  or  weeks  and  are 
accompanied  at  first  by  some  pain.  They  continue  to  recur  for 
years.     They  may  be  associated  with  attacks  of  migraine. 


MOTOR    DISORDERS   OF    SPECIAL    XERVES. 


105 


In  diphtheritic  eye  palsies  the  first  three  or  four  nuclei  of  the 
series  making  up  the  origin  of  the  third  nerve  are  oftenest  affected, 
causing  paralysis  of  accommodation,  paralysis  of  the  iris  and  of  the 
internal  rectus,  the  three  muscles  concerned  in  accommodating  the 
eye  to  near  objects. 

Pathology. — In  the  rheumatic  palsies  there  is  a  low  grade  of 
peripheral  neuritis,  and  the  same  is  true  of  most  diphtheritic  and 
other  palsies  of  infectious  origin.     In  syphilitic  and  tabetic  palsies 


Fig.  59.— Shutter  for  Testing  Pupil  Reflex.  The  apparatus  admits  of  using  colored 
glasses  for  testing  hysteria  and  malingering;  also  of  the  use  of  a  Maddox  prism  for  testing 
tli.-  eye  muscles. 


there  is  usually  a  specific  basilar  meningitis  involving  the  nerve 
roots.  The  meningitis  may  be  slight  or  may  amount  to  gummatous 
deposit.  In  functional  and  some  periodical  palsies  there  is  a  vaso- 
motor disturbance  causing  congestion  or  amemia  or  perhaps  simply 
inhibition  of  the  nuclear  centres.  Some  periodical  palsies  have 
been  found  to  be  due  to  small  tumors  involving  the  nerve  r<>"'.  In 
rare  cases  there  is  primary  muscular  atrophy  of  the  eyeball  nerves, 
or  primary  degeneration  of  the  nuclear  centres,  or  a  cerebral  lesion. 
The  nuclear  inflammation  forming  " polio-enoephalitis  superior"  is 
a  disease  probably  infectious  and  quite  similar  to  anterior  polio- 
myelitis. 


106  DISEASES   OF  THE   NERVOUS    SYSTEM. 

Diagnosis. — One  must  first  determine  how  extensively  the 
muscles  supplied  by  the  third  are  involved. 

If  only  the  levator  palpebree,  there  is  simply  falling  of  the  lid. 
If  the  eyeball  muscles  are  involved,  Ave  get  the  following  symptoms. 
They  are : 

Limitation  of  movement  of  the  globe. 

Strabismus  and  secondary  deviation* 

Erroneous  projection. 

Double  vision  or  diplopia,  which  is  either  simple  or  crossed. 

Paralysis  of  the  iris  or  iridoplegia  and  of  the  ciliary  muscle  or 
cycloplegia. 

Concentric  limitation  of  the  visual  field. 

All  these  points  must  be  tested,  but  the  detailed  knowledge  of 
them  is  best  gained  by  consulting  ophthalmological  works. 

The  extent  of  involvement  of  eye  muscles  can  generally  be  suffi- 
ciently tested  by  making  the  patient  move  the  affected  eye  in  various 
directions,  and  by  testing  for  accommodation  and  for  the  pupillary 
reaction  to  light. 

Paralysis  of  the  iris,  or  iridoplegia,  and  of  the  ciliary 
muscle — cycloplegia. 

The  motor  fibres  of  the  third  nerve  to  the  iris  supply  the 
sphincter,  and  when  paralyzed  there  are  dilatation  and  immobility  of 
the  pupil,  a  condition  known  as  mydriasis.  Fibres  from  the  same 
nucleus  innervate  the  ciliary  muscle,  and  the  iris  and  this  muscle 
are  usually  paralyzed  together.  Paralysis  of  the  ciliary  muscle  is 
called  cycloplegia.  In  this  latter  condition  there  is  loss  of  power 
of  accommodation.  Iridoplegia  and  cycloplegia  are  usually  due 
to  local  disease  of  the  eye  or  to  the  use  of  mydriatic  drugs. 
Occasionally  they  are  observed  after  diphtheria  or  in  multiple 
sclerosis.  It  may  occur  in  locomotor  ataxia,  and  in  disease  of  the 
lower  cervical  cord  involving  the  cilio-spinal  centre,  which  when 
destroyed  causes  a  myosis. 

Paralysis  of  the  levator  palpebral,  causing  ptosis,  is  sometimes 
seen  alone,  but  usually  other  branches  of  the  third  nerve  are  in- 
volved. A  functional  palsy  of  the  lids  sometimes  occurs  in  anaemic 
and  nervous  people  at  the  time  of  waking.  It  is  a  temporary  wont- 
ing or  waking  ptosis. 

Paralysis  of  the  sympathetic  fibres  of  the  eye  causes  con- 
traction of  the  pupil  (myosis)  from  the  unopposed  action  of  the  third 
nerve.  There  is  also  a  slight  prominence  of  the  eye  and  slight 
ptosis  from  an  involvement  of  the  nerves  that  supply  Midler's 
muscle.  The  pupil  does  not  dilate  when  the  skin  of  the  cheek  or 
neck  is  irritated.  This  is  a  condition  known  as  loss  of  skin  reflex. 
In  locomotor  ataxia  there  is  often  a  rigidity  of  the  constricting  fibres 


MOTOR    DISORDERS    OF    SPECIAL    NERVES.  107 

of  the  iris,  while  the  ciliary  muscle  continues  to  act.  The  pupil  is 
then  small  and  does  not  respond  to  light,  while  it  does  respond  to 
accommodation.     This  is  known  as  the  Argyll- Robertson  pup-il. 

II.  Paralysis  of  the  Fourth  Nerve. — This  is  a  rare  affec- 
tion and  not  always  easily  detected.  The  causes  are  much  the  same 
as  those  of  palsy  of  the  third  nerve. 

The  symptoms  are  slight  convergent  strabismus  when  the  eye  is 
moved  downward  and  diplopia  on  looking  down.  There  is  defect  in 
the  movements  of  the  eye  downward  and  outward. 

Paralysis  of  the  sixth  nerve  (abducens)  is  the  most  fre- 
quent of  eye  palsies,  and  occurs  especially  often  in  syphilis  and  in 
locomotor  ataxia.  It  causes  convergent  strabismus  and  double 
vision. 

III.  Progressive  Ophthalmoplegia  (Progressive  Upper  Bul- 
bar Palsy). — Besides  the  palsies  already  described,  there  occur  cer- 
tain forms  which  have  a  peculiar  origin  and  course.  They  begin 
slowly,  as  a  rule,  and  steadily  progress.  In  some  cases  only  do  they 
reach  a  certain  stage  and  then  remain  chronic.  The  term  "  progres- 
sive" applies  fairly  well  to  them.  They  often  affect  the  third, 
fourth,  and  sixth  nerves  together.  In  accordance  with  the  muscles 
invaded,  these  palsies  are  called  external,  Internal,  partial,  and  total. 
Thus  if  those  branches  of  the  third  nerve  supplying  the  iris  and 
ciliary  muscle  are  involved  alone,  it  is  ophthalmoplegia  interna;  if 
the  other  branches  are  involved,  it  is  called  ophthalmoplegia  externa. 

Definition. — Progressive  ophthalmoplegia  is  a  degenerative  dis- 
ease of  the  nuclei  of  the  motor  nerves  of  the  eye.  It  is  in  most 
cases  the  same  disorder  as  of  bulbar  paralysis  and  progressive  mus- 
cular atrophy. 

Etiology. — It  develops  between  the  ages  of  fifteen  and  forty,  but 
may  occur  later.  The  sexes  are  equally  affected.  Lead,  diphtheria, 
traumatism,  syphilis,  appear  sometimes  to  be  the  cause.  It  may 
complicate  locomotor  ataxia;  more  often  it  forms  part  of  progressive 
muscular  atrophy. 

The  symptoms  are  often  not  noticed  until  the  disease  is  Pax  ad- 
vanced. The  vision  is  not  disordered,  and  there  is  only  a  gradual 
limitation  of  mobility  of  the  eyeball.  A  slight  drooping  of  the  lids, 
causing  a  sleepy  look,  or  a  slight  squint,  usually  divergent,  is 
noticed.  Then  upon  examination  it  is  found  that  the  eye  cannot 
follow  the  finger,  except  to  a  slight  extent.  This  peculiar  physi- 
ognomy is  known  as  the  "Hutchinson  face''  (see  Fig.  60).  The 
iris  reacts  to  accommodation  and  light  usually.  Double  vision  may 
be  present.  Usually  the  patient  accustoms  himself  to  monocular 
vision.  The  disease  lasts  a  long  time,  and  it  may  become  station- 
ary.    If  complicated  with  progressive  muscular  atrophy,  however, 


108 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


the  course  is  relatively  rapid,  death  occurring  from  the  latter  dis- 
ease in  two  or  three  years. 

Pathological  Anatomy. — In  all  progressive  cases  there  is  a  de- 
generative atrophy  of  the  nuclear  cells.  In  a  few  rare  cases  no 
lesion  has  been  found,  and  in  a  few  stationary  cases  the  anatomical 
change  is  that  of  neuritis. 

The  treatment  is  that  for  the  disease  which  it  complicates  or  the 
condition  which  causes  it.  That  is  to  say,  it  is  the  treatment  for 
locomotor  ataxia,  progressive  muscular  atrophy,  syphilis,   or  lead 


Fig.  60.— Showing  "Hutchinson  Face." 


poisoning.  Iodide  of  potassium,  strychnine,  arsenic,  nitrate  of 
silver,  and  phosphorus  may  be  given.  Electricity  is  of  very  doubt- 
fid  value,  and  only  the  galvanic  current  would  be  indicated.  Gen- 
eral tonic  measures  and  rest  to  the  eyes  should  be  employed. 

Musculak  Asthenopia  and  Muscular  Insufficiencies.* — 
This  is  a  term  employed  to  indicate  a  lack  of  equilibrium  of  the 
muscles  of  the  eye,  as  a  result  of  which  the  visual  axes  cannot  be 
kept  parallel  without  an  effort.  This  effort  is  often  unconscious, 
and  shows  itself  only  by  a  ready  tiring  of  the  eye  on  attempting  to 
read,  or  by  the  production  of  headaches  and  cerebral  pareesthesiae. 
Examination  of  the  eye  by  means  of  prisms  reveals  the  special 
character  of  the  trouble. 

When  the  eye  muscles  act  normally  the  condition  is  called  one 
*  Partial  ophthalmoplegia  occurs  also  in  myasthenic  paralysis. 


MOTOR    DISORDERS   OF    SPECIAL   NERVES.  109 

of  orthophoria.  When  some  of  the  muscles  are  -weak  it  is  called 
heterophoria.  There  are  various  forms  of  heterophoria,  viz. :  eso- 
phoria,  a  tending  of  the  visual  lines  inward,  from  weakness  of  the 
extend;  exophoria,  a  tending  of  visual  lines  outward;  hyperphoria, 
a  tending  of  the  visual  line  of  one  eye  above  its  fellow. 

The  condition  is  tested  in  various  ways.  The  simplest  is  this: 
Refractive  errors  having  been  corrected,  a  series  of  prisms  is  placed 
over  the  eye,  at  first  with  the  base  inward,  while  the  patient  looks  at 
a  candle  twenty  feet  distant.  The  prisms  are  increased  in  strength 
until  the  patient  can  no  longer  coalesce  the  images.  The  degree  of 
prism  is  noted,  and  this  indicates  the  strength  of  abduction  or  of 
the  externi.  The  same  process  is  gone  through  with  for  the  in- 
terni,  the  base  of  the  prism  being  out.  The  externi  should  over- 
come a  prism  of  about  8°,  the  intend  one  of  23°  to  25°  or  more. 
There  are  great  individual  variations,  and  there  is  also  considerable 
variation  in  individuals. 

The  above  tests  measure  the  amount  of  abduction  and  adduction. 

To  test  the  presence  of  heterophoria,  the  writer  uses  the  Maddox 
double  prism  held  in  a  frame.  The  line  where  the  bases  of  the  two 
prisms  unite  is  brought  directly  over  one  eye,  and  is  held  there  in  a 
perfectly  horizontal  position  Avhile  the  patient  looks  at  a  candle 
twenty  feet  away.  A  red  glass  is  at  the  same  time  held  over  the 
other  eye.  With  the  eye  covered  by  the  double  prism  the  patient 
sees  double,  one  flame  being  above  the  other;  with  the  other  eye  he 
sees  a  red  flame  lying  just  between  the  two  white  ones.  If  the  red 
flame  is  directly  in  a  vertical  line,  there  is  orthophoria;  but  if  it  lies 
to  one  side  or  the  other  there  is  exophoria  or  esophoria  according 
as  the  red  flame  was  on  the  side  opposite  to  the  eye  covered  with 
red  glass  or  on  the  same  side.  If  heterophoria  is  found,  prisma  are 
placed  over  the  eye  until  the  three  lights  are  in  a  vertical  line.  The 
number  of  the  prism  required  to  correct  the  heterophoria  indicates 
its  extent  in  degrees.  By  changing  the  double  prism  so  that  its 
common  base  line  is  vertical,  the  test  for  hyperphoria  can  be  made.* 

Muscular  asthenopia  is  said  to  cause  a  disturbance  of  vision, 
vertigo,  migraine,  cerebral  paresthesia,  and  pains  in  the  head,  more 
particularly  in  the  occipital  and  cervical  region.  It  is  believed  bo 
be  a  possible  factor  in  producing  choreic  twitchingsin  the  face.  In 
neurasthenic  persons  it  may  cause  a  wider  range  of  nervous  symp- 
toms. It  is  said  to  be  an  essential  factor  in  causing  epilepsy, 
chorea,  and  hysteria.  The  author  cannot  accept  this  latter  view, 
and  believes  that  the  importance  of  muscular  asthenopia  in  causing 

*  More  elaborate  and  exact  methods  have  been  devised  by  Dr.  Stevens  and 

are  employed  by  ophthalmologists. 


110  DISEASES   OF   THE    NERVOUS   SYSTEM. 

general  nervous  symptoms  is  not  great.  Much  of  it,  if  not  all,  may 
be  relieved  by  correcting  refractive  errors  and  by  helping  the  gen- 
eral health  of  the  patient. 

The  treatment  of  it,  after  all  myopia,  or  hypermetropia,  or 
astigmatism,  if  present,  is  relieved,  consists  in  building  up  the  gen- 
eral health,  the  systematic  use  of  prisms  for  training  the  muscles, 
the  wearing  of  proper  glasses.  Some  advise  graduated  or  complete 
tenotomies  according  to  the  method  of  Stevens. 

Spasmodic  Diseases  of  the  Ocular  Muscles. 

These  are:  (1)  Conjugate  deviation  from  spasm;  (2)  irregular 
and  associated  spasms  from  convulsive  and  irritative  brain  disorder; 
(3)  nystagmus. 

Spasmodic  conjugate  deviation  occurs  from  an  irritating  lesion  of 
the  ocular  nuclei  or  of  the  brain  in  its  cortical  motor  areas  and  tracts. 
Irregular  spasmodic  movements  occur  in  meningitis,  hydrocephalus, 
and  in  lesions  involving  the  semicircular  canals.  Peculiar  asso- 
ciated spasms  occur  in  hysterical  attacks.  Various  spasmodic  move- 
ments and  contractions  of  individual  eye  muscles  occur  from  ocular 
disease,  errors  of  refraction,  muscular  weakness,  and  paralysis  of 
certain  eye  muscles. 

Rhythmical  spasm  or  nystagmus  occurs  as  the  result  of  hereditary 
visual  weaknesses  and  refractive  errors  of  various  kinds,  in  albinoes, 
and  in  chronic  hydrocephalus.  It  is  found  usually  in  neurotic  cases 
associated  with  ocular  defects,  in  multiple  sclerosis,  and  sometimes 
in  epilepsy,  chorea,  hysteria,  neurasthenia,  and  insanity.  It  occurs 
in  certain  degenerative  nervous  disorders  such  as  disseminated  sclero- 
sis, hereditary  ataxia,  tumors,  especially  of  the  cerebellum,  and  other 
focal  lesions,  and  in  meningitis.  It  occurs  in  miners,  and  is  called 
miners'  nystagmus.  It  may  be  a  reflex  symptom  from  a  remote 
irritation. 

In  nystagmus  the  oscillation  of  the  eyeballs  is  usually  lateral. 
It  may  be  brought  out  when  slight  in  degree  by  causing  the  patient 
to  look  steadily  to  one  side.  Vertical  and  a  kind  of  rotating  nys- 
tagmus sometimes  occur,  and  are  due  to  much  the  same  causes  as 
those  of  lateral  nystagmus. 

Spasm  of  the  levator  palpebrce  is  sometimes  seen  and  is  usually 
tonic. 

The  above  troubles  are  usually  symptomatic,  and  their  treat- 
ment depends  upon  correction  of  some  local  disease  or  cerebral 
neurosis. 


motor  disorders  of  special  nerves.  ill 

The  Motor  Branch  of  the  Fifth  Cranial  Nerve. 

The  anatomy  of  this  nerve  is  described  under  the  head  of  the 
neuralgias  of  the  trigeminus. 

The  diseases  of  the  motor  branch  of  the  trigeminus  are  rare,  and 
generally  symptomatic  of  some  more  general  disorder. 

Trismus  (lockjaw)  is  the  only  important  independent  affec- 
tion of  this  motor  nerve.  It  is  a  tonic  spasm  of  the  muscles  of 
mastication. 

Etiology. — It  occurs  in  infants,  usually  through  infection  from 
the  umbilicus.  It  is  then  known  as  trismus  nascentium.  It  forms 
part  of  the  symptoms  of  tetanus  and  rabies.  It  may  be  symptomatic 
of  brain  disease,  and  forms  one  of  the  manifestations  of  the  epileptic 
fit.  There  may  be  a  reflex  trismus  from  irritations  of  the  teeth 
and  jaw,  and  from  gastro-intestinal  trouble.  Neuritis  and  hysteria 
are  causes  of  trismus  and  it  may  be  associated  with  a  trigeminal 
neuralgia. 

Symptoms. — There  is,  as  shown  above,  a  symptomatic,  an  in- 
fectious, a  reflex,  a  neuritic,  and  a  hysterical  trismus.  In  all,  the 
symptoms  are  very  manifest.  The  jaws  are  firmly  locked  and  the 
masseters  and  temporals  stand  out.  If  the  disease  is  unilateral, 
which  is  rarely  the  case,  the  lower  jaw  is  pushed  over  toward  the 
sound  side. 

The  treatment  of  both  tonic  and  clonic  spasms  depends  upon  the 
cause.  Symptomatically,  morphine  is  to  be  given,  and  later  the 
antispasmodics,  such  as  the  bromides  and  chloral.  In  rheumatic 
cases  hot  applications  and  diaphoretics  are  indicated. 

The  Facial  Nerve. 

Anatomy. — The  facial  nerve  has  its  primary  origin  in  a  single 
nucleus  deeply  situated  in  the  lower  part  of  the  pons  (Fig.  61).  It 
belongs  to  the  same  series  of  nuclei  as  the  motor  nuclei  of  the  vagus, 
glosso-pharyngeal,  and  of  the  spinal  accessory;  in  other  words,  it  is 
a  prolongation  of  the  lateral  horn  of  the  spinal  cord.  It  has  not  a 
nucleus  common  to  it  with  the  sixth,  as  is  usually  stated.  Those 
fibres  of  the  nerve  which  go  to  the  orbicularis,  however,  appear  to 
come  from  a  nucleus  in  the  third-nerve  series  and  to  reach  the  knee 
of  the  facial  by  the  posterior  longitudinal  bundle  (Mendel).  The 
deep  fibres  of  the  facial  take  a  tortuous  course,  passing  inward, 
dorsally,  then  curving  down  and  out  around  the  nucleus  of  the  sixth 
nerve  (Fig.  G2).  The  cortical  origin  of  the  seventh  is  in  the  lower 
part  of  the  central  convolutions,  especially  the  precentral.  The 
fibres  pas's  down  through  the  knee  of  the  internal  capsule  and  enter 


H'-i 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


the  crusta  at  the  inner  side  of  the  pyramidal  or  motor  tract.  They 
decussate  and  reach  the  nucleus.  The  nerve  has  its  exit  at  the 
posterior  edge  of  the  pons,  external  to  the  sixth  nerve.  It  then  has 
to  take  a  long  course  through  a  bony  canal,  during  which  it  receives 
taste  fibres  from  the  second  or  third  branch  of  the  trigeminus  (or 
the  glosso-phary ngeal) .  These  fibres  leave  the  nerve  at  the  chorda 
tympani,  and  join  the  lingual  branch  of  the  fifth  nerve  to  supply 
taste  to  the  anterior  two-thirds  of  the  tongue. 

The  facial  nerve  supplies  motion  to  all  the  muscles  of  the  face ; 
to  the  stapedius,  stylo-hyoid,  buccinator,  and  platysma  myoid.     It 

B. 


Fig.  01.— Showing  the  Position  op  the  Cranial  Nuclei  in  the  Medulla. 

also  contains  trophic  and  secretory  fibres.     It  does  not  supply,  how- 
ever, the  muscles  of  mastication. 

The  taste  fibres  of  the  facial  nerve  come  in  most  cases  from  the 
second  branch  of  the  fifth  via  Meckel's  ganglion,  the  large  superior 
petrosal  nerve,  and  geniculate  ganglion.  In  other  cases  they 
come  from  the  glosso-phary  ngeal  nerve  via  the  ganglion  petro- 
sum,  Jacobson's  nerve,  tympanic  plexus,  and  geniculate  ganglion 
(Fig.  63).  Some  think  that  the  intermediary  nerve  of  Wrisberg, 
which  arises  in  the  upper  part  of  the  glosso-phyaryngeal  nucleus  and 
connects  with  the  geniculate  ganglion,  carries  taste  fibres  to  the  facial. 

The  facial  nerve  being  motor,  its  diseases  are  spasmodic  and 
paralytic.  The  two  common  types  are  facial  tic  and  facial  palsy, 
but  there  are  other  minor  forms. 

The  spasmodic  disorders  are  (1)  diffuse  facial  spasm  or  mimic  tic 
and  (2)  spasm  of  single  branches,  including  (a)  blepharospasm  and 
(b)  nictitating  spasm. 


MOTOR    DISORDERS    OF    SPFXIAL    NERVES. 


113 


Facial  Spasm  (Mimic  Tic). — This  is  a  disease  characterized  by 
intermittent,  involuntary  Switchings  of  the  facial  muscles.  It  is 
always  chronic  and  generally  unilateral. 

Etiology. — It  is  a  disease  of  middle  and  later  life,  and  occurs 


2       *o      ^ 


Fig.  62.— Showing  the  Relative  Position  op  the  Nuclei   of  the  Motor  Cranial 
Nerves  (Van  Gehuchten). 

oftener  in  women ;  there  is  usually  a  neuropathic  constitution ;  it  is 
not  hereditary.  The  exciting  causes  are  anxiety,  shock,  injury,  and 
exposures.  It  often  has  a  reflex  cause,  usually  from  irritation  of 
some  branch  of  the  trigeminus  or  the  cervico-brachial  nerves ;  rarely 


n  inaac  Inf 
n  ophUuilm. 


u.l7iC4LUS 


gg  bphettD  baled: 

n petit pttraut  iiiscrf — 

qq.otiqujo 

n  dc/tt 


■n  d  m  at  Ictncr 

de,  Jatubiuit- 
Ulnpurai  ilipcrf. 


r  eiu.  dig  &  du.  stylo-  hyoui 
*&r.  temporo  ■  (annte* 
>6r  cctulco    fu&iu.U- 


Fig.  63.— Showing  tite   Coubstc  r>p  the  Taste  Praam   in  thi:  Banana  and  Fifth 

Ni.i:vks  i  Clause). 

from  eye  strain.  It  is  sometimes  associated  witBi  (fio  douloureux. 
Organic  diseases,  such  as  tumors  and  softening,  aflbeting  th«  meros 
nucleus  in  the  pons  or  the  cerebral  centres,  eause  a  symptomatic  tic. 
but  not  the  true  disease.     Thus  we  may  have  a  poflt-hemiplegia  tic 


114  DISEASES   OF   THE    NERVOUS    SYSTEM. 

or  a  tic  due  to  cortical  lesion  and  associated  with  epilepsy.  True 
facial  tic  may  also  be  caused  by  irritation  or  disease  of  the  nerve 
or  its  nucleus. 

Symptoms. — The  disease  usually  begins  slowly  and  the  orbicu- 
laris muscle  and  zygomatici  are  earliest  affected.  It  rarely  goes 
above  the  eyebrows,  i.e.,  to  the  corrugator  supercilii  and  frontalis. 
The  lower  branch  of  the  facial  is  little  affected.  The  spasm  is  a 
clonic  one ;  the  muscles  of  the  face  are  affected  by  a  series  of  light- 
ning-like twitches,  with  intervals  of  rest.  Sometimes,  however,  the 
contraction  becomes  tonic  and  lasts  several  seconds  or  more.  There 
is  no  pain.  The  spasm  is  increased  by  emotions,  nervous  excite- 
ment, conversation,  exposure  to  light  and  cold,  and  is  at  its  worst 
when  the  patient  himself  is  most  depressed.  It  is  a  very  good  gauge 
of  the  general  nervous  stability  of  the  patient.  There  is  no  paraly- 
sis or  atrophy,  and  there  are  no  secretory  or  trophic  symptoms. 
The  taste  fibres  are  rarely  involved,  though  occasional  subjective 
sensations  of  taste  have  been  felt.  The  electrical  irritability  is 
either  unchanged  or  slightly  increased. 

Associated  movements  of  the  eyes,  of  the  jaw  muscles  and  cheek 
muscles  are  sometimes  seen.  Pressure  over  the  motor  points  of  the 
nerve  will  sometimes  arrest  the  movements  for  a  time.  The  disease 
is  a  unilateral  one.     It  lasts  for  years  and  even  for  the  lifetime. 

Pathology. — There  is  no  known  anatomical  change  in  idiopathic 
cases.  The  disease  is  allied  in  character  to  wryneck  and  other 
chronic  tics,  and  is  a  motor  correlative  to  the  severe  neuralgias  like 
tic  douloureux.  In  these  cases  it  is  probably  the  expression  of  some 
local  cortical  degeneration  of  light  grade.  The  disease  is  sometimes 
a  pure  reflex  neurosis  from  ocular  or  dental  irritations. 

Diagnosis. — Idiopathic  facial  spasm  is  chronic,  unilateral,  unac- 
companied by  pain  or  paralysis.  It  is  distinguished  from  facial 
spasms  of  organic  origin  by  the  fact  that  the  latter  always  have 
some  other  symptoms.  Thus  facial  habit  chorea  is  bilateral ;  spasm 
from  cortical  disease  is  attended  by  disturbance  of  consciousness  and 
comes  on  in  paroxysms;  the  spasm  occurring  after  hemiplegia  is 
usually  tonic,  and  so  is  hysterical  facial  spasm. 

Prognosis. — The  disease  is  in  most  cases  incurable,  especially 
after  it  has  lasted  some  time.  If  a  reflex  cause  exist,  the  prognosis 
is  better.     Life  is,  however,  never  endangered  by  it. 

Treatment. — The  most  important  thing  is  attention  to  the  general 
health,  removal  of  all  depressing  influences,  rest,  and  freedom  from 
excitement.  Among  specific  remedies  arsenic,  the  bromides,  can- 
nabis indica,  gelsemium,  conium,  hyoscyamus,  strychnine,  codeine, 
and  morphine  are  recommended.     Morphine  is  useful,  but  must  be 


MOTOR   DISORDERS    OF   SPECIAL   NERVES.  115 

tried  carefully  and  in  small  doses.  Coniuin  lessens  the  spasm,  but 
this  drug  has  to  be  given  in  large  doses  and  is  not  entirely  free  from 
danger.  Hyoscine  and  gelsemium  sometimes  do  good.  Careful 
examination  of  the  teeth,  eyes,  nose,  stomach,  and  uterus  for  reflex 
irritation  is  imperative. 

Galvanism,  if  carefully  and  persistently  applied,  almost  always 
helps.  It  should  be  given  daily.  Various  methods  are  described. 
The  best  way  is  to  place  the  negative  pole  on  the  sternum  or  back 
of  the  neck,  and  the  positive  pole  over  each  motor  point  of  the  nerve 
for  one  to  two  minutes,  then  over  the  occiput  and  over  the  facial 
cortical  area  for  the  same  time.  Currents  of  from  two  to  five  milliam- 
peres  should  be  used.  Neurectomy  of  the  supraorbital,  continuous 
pressure  on  the  motor  points,  stretching  the  nerve  itself,  are  all 
measures  which  may  be  considered  valueless.  Freezing  the  skin 
over  the  nerve  with  chloride  of  methyl  has  been  recommended  by 
Mitchell.  Blistering  and  cauterization  are  needless  inflictions. 
The  anesthetization  of  the  conjunctiva  with  cocaine  is  often  help- 
ful, both  in  diagnosis  and  treatment. 

Blepharospasm  is  the  name  given  to  a  spasm  of  the  orbicularis 
palpebrarum.  It  is  generally  caused  by  diseases  of  the  eye,  and  its 
nature  and  treatment  are  matters  belonging  to  ophthalmology.  It 
is  a  rare  symptom  of  hysteria. 

Nictitating  or  winking  spasm  is  a  clonic  spasm  of  the  orbicu- 
laris, and  usually  forms  part  of  habit  chorea  or  is  a  symptom  of 
hysteria. 

Tonic  facial  spasm  is  sometimes  seen  in  major  hysteria. 

Facial  Palsies. 

The  paralyses  of  the  facial  nerve  may  be  due  to  lesions  that  are 
central,  nuclear,  meningeal,  or  peripheral. 

Facial  palsy  of  central  origin  is  almost  invariably  an  accompani- 
ment of  hemiplegia  and  is  due  to  hemorrhage,  softening,  inflamma- 
tion, or  tumor  of  the  brain.  The  lower  two  branches  of  the  facial 
are  chiefly  involved. 

Facial  palsy  of  nuclear  origin  is  very  rare  and  is  an  accompani- 
ment of  glosso-labial  palsy,  of  diphtheritic  palsj^,  or  of  gross  lesions 
of  the  pons. 

Facial  palsy  of  meningeal  origin  is  due  to  tumors,  meningitis,  or 
fracture  of  the  base  of  the  brain,  and  is  accompanied  by  lesion  of 
other  cranial  nerves.  Syphilis  is  the  most  important  factor  here. 
All  these  forms  are  simply  part  of  other  diseases. 

Peripheral  facial  palsy  (Bell's  palsy)  is  the  common  type 
of  facial  paralysis. 


116  DISEASES    OF   THE    NERVOUS   SYSTEM. 

Etiology. — The  typical  cases  of  this  disease  are  due  to  exposure, 
infection,  and  so-called  rheumatic  influences.  Males  are  oftener 
affected,  and  the  common  age  is  between  twenty  and  forty.  It  is 
more  frequent  in  the  winter  and  in  temperate  climates.  It  is  not 
hereditary.  A  neuropathic  tendency  predisposes  to  it.  Syphilis 
rarely  causes  an  isolated  facial  palsy ;  in  fact,  it  is  apt  to  leave  this 
nerve  alone  (Hutchinson).  Facial  palsy  may  occur  in  multiple 
neuritis,  when  it  is  often  bilateral,  and  in  locomotor  ataxia.  Non- 
typical  and  accidental  cases  of  peripheral  facial  palsy  are  due  to  in- 
juries, fracture  of  the  petrous  bone,  or  ear  disease.  Forceps  pres- 
sure in  difficult  labor  causes  some  cases,  and  a  very  few  have  been 
congenital. 

Symptoms. — The  disease  comes  on  rather  suddenly,  and  reaches 
its  height  within  a  few  hours,  or,  at  most,  two  or  three  days.  Pre- 
ceding and  accompanying  the  onset  there  may  be  some  pain  about 
the  ears  and  a  little  swelling  is  sometimes  seen. 

The  patient  feels  a  subjective  discomfort  on  the  paralyzed  side 
of  the  face.  He  finds  that  he  cannot  completely  shut  the  eye;  if  he 
tries  to  chew  on  the  affected  side,  food  gets  between  the  teeth  and 
cheek.  He  cannot  pucker  the  lips,  and  his  speech  is  a  little  muffled. 
The  appearance  of  the  face  is  most  characteristic. 

On  the  affected  side  the  wrinkles  are  smoothed  out,  the  angle  of 
the  mouth  is  lower,  the  mouth  is  drawn  at  first  to  the  sound  side, 
and  owing  to  this  distortion  the  tongue  appears  not  to  be  protruded 
straight.  In  laughing  or  other  emotional  movements  of  the  face, 
the  trouble  is  most  clearly  brought  out.  But  the  most  characterized 
appearance  is  produced  by  telling  the  patient  to  shut  the  eyes  tightly 
and  draw  out  the  angles  of  the  mouth  so  as  to  show  the  teeth 
(Fig.  64).  The  eye  on  the  palsied  side  is  not  closed,  and  the  eye- 
ball turns  up,  showing  the  white  of  the  eye.  This  test  of  the  palsy 
is  better  than  any  examination  of  the  wrinkles  and  folds  of  the 
face,  for  in  children  and  in  the  young  and  plump  these  differences 
in  the  two  sides  of  the  face  are  not  very  marked,  especially  in  the 
slighter  cases.  The  nostril  on  the  affected  side  does  not  expand 
on  forced  inspiration;  the  eye  is  apt  to  be  watery  and  the  conjunc- 
tiva somewhat  injected. 

If  the  disease  extend  well  up  into  the  Fallopian  canal,  so  as  to 
involve  the  nerve  to  the  stapedius,  that  muscle  is  paralyzed,  the 
tensor  tympani  acts  unopposed,  the  drum  is  tightened,  and  unusual 
sensitiveness  to  sounds  results.  This  is  rare,  however;  most  of  the 
ear  symptoms  in  facial  palsy  being  due  to  a  concomitant  disorder  of 
the  tympanum  or  the  acoustic  nerve. 

If  the  disease  involve  the  nerve  between  the  geniculate  ganglion 


MOTOR    DISORDERS    OF    SPECIAL    NERVES. 


117 


and  the  point  where  the  chorda  tympani  is  given  off  (see  Fig.  63), 
some  loss  of  taste  follows,  and  this  is  a  frequent  symptom,  but  not 
one  of  long  duration.  If  the  disease  is  located  more  centrally  than 
the  geniculate  ganglion  or  more  peripherally  than  the  chorda  nerve, 
taste  is  not  involved.  Usually,  when  there  is  no  taste  involvement, 
it  is  because  the  lesion  is  peripheral.     By  an  examination  of  the 


Fig.  64.— Patient  with  Left  Facial  Palsy  Attempting  to  Close  Both  Eyes  and 

Show  the  Teeth. 

taste  sense-  and  of  the  hearing,  the  locution  of  the  trouble  can  be 
accurately  made  out. 

After  a  few  weeks  some  wasting  of  the  face  may  be  noted,  but 
this  is  never  very  great. 

The  electrical  reactions  are  characteristic  and  important,  since 
typical  or  partial  degeneration  reactions  can  usually  be  observed. 
For  a  few  days  there  is  an  increase  in  irritability  of  the  muscles  to 
both  faradic  and  galvanic  currents.  This  is  followed  by  a  gradual 
loss  or  diminution  in  faradic  irritability,  while  the  galvanic  irrita- 
bility remains  sometimes  increased  for  a  while  and  then  falls.  At 
the  same  time  a  reversal  of  poles  and  a  sluggish  contraction,  par* 
ticularly  the  latter,  may  be  netted.  At  the  end  of  five  or  six  weeks 
faradic  irritability  ought  to  begin  to  return.     Great  variations  are 


118  DISEASES    OF   THE    XERVOUS    SYSTEM. 

found  ill  the  electrical  reactions  dependent  upon  the  severity  of  the 
case.  For  example,  in  very  severe  cases  the  electrical  irritability 
may  be  almost  or  entirely  absent  for  days  and  even  weeks. 

If  the  disease  lasts  for  two  months  or  more  and  the  palsy  is  not 
a  complete  one,  secondary  contractures  begin  to  appear.  The  mouth 
now  becomes  drawn  to  the  affected  side,  and  the  nasolabial  fold 
becomes  deeper  than  that  on  the  sound  side.  In  smiling  or  speak- 
ing or  other  facial  movements  there  is  an  excess  of  movement  on  the 
paralyzed  side,  the  teeth  and  upper  gums  in  particular  showing  ab- 
normally. This  is  particularly  the  case  in  old  palsies  occurring  in 
childhood. 

Pathology. — The  disease  in  its  typical  form  is  due  to  a  diffuse 
neuritis.  This  attacks  the  periphery  of  the  nerve  in  the  face  and 
extends  rapidly  up  into  the  Fallopian  canal  as  far  as  the  geniculate 
ganglion.  The  inflammation  sometimes  attacks  most  the  peripheral 
filaments;  at  other  times  it  is  more  central.  The  old  idea  that  it 
Was  always  a  perineuritis  of  the  nerve  in  the  "Fallopian  canal  is  in- 
correct (Minkowski). 

Facial  paralysis  is  not,  as  is  usually  taught,  a  rheumatic  disease. 
It  is  not  caused  by  rheumatic  poisoning,  nor  does  it  occur  in  persons 
who  have  a  particular  rheumatic  constitution,  and  it  is  not  in  the 
majority  of  cases  associated  with  a  distinctly  rheumatic  etiology. 
It  is  rather  an  infectious  disease  and  should  be  classed  as  such  or  as 
a  post-infectious  disease.  Many  cases  will  be  found  to  occur  after 
influenza  or  some  infection  which  is  allied  to  it.  Indeed,  it  has 
seemed  to  me  more  like  a  cold  of  the.  seventh  nerve  than  a  rheuma- 
tism. This  view  is  borne  out  by  my  experience  in  the  treatment 
which  shows  that  antirheumatic  drugs,  like  the  salicylates  and 
iodides,  do  not  appreciably  modify  its  course. 

Diagnosis. — The  recognition  of  the  palsy  is  made  easy  by  caus- 
ing the  patient  to  contort  the  face.  In  children  it  requires  more 
care  to  detect  the  side  affected. 

It  is  important  to  determine  whether  the  palsy  is  cerebral,  nu- 
clear, basilar,  or  peripheral.  If  the  cause  is  cerebral,  the  upper 
branch  of  the  nerve  is  little  affected  and  the  patient  can  close  the  eye. 
The  nerve  and  muscles  show  no  degenerative  reactions. 

Nuclear  palsy  is  very  rare  and  is  accompanied  with  other  symp- 
toms, especially  those  of  involvement  of  other  cranial  nerves.  A 
history  of  diphtheria,  lead  palsy,  or  bulbar  paralysis  is  obtained. 

In  palsies  due  to  lesions  at  the  base  of  the  brain,  such  as  gummy 
meningitis,  the  auditory  and  other  cranial  nerves  are  involved  and 
there  are  signs  of  brain  syphilis.  By  testing  the  sense  of  taste  and 
hearing,   the  location  of  the  peripheral  trouble  can  be  made  out. 


MOTOR    DISORDERS   OF    SPECIAL   NERVES.  119 

Thus  if  there  be  loss  of  taste  on  the  anterior  two-thirds  of  the 
tongue,  the  lesion  must  be  between  the  geniculate  ganglion  and 
the  point  at  which  the  chorda  tympani  is  given  off.  If  the  taste  be 
net  involved,  the  lesion  must  be  central  or  peripheral  of  the  part  of 
the  nerve  which  includes  the  chorda.  Practically  in  most  cases  it 
is  peripheral  to  it.  If  central  the  disease  is  usually  of  syphilitic  or 
tuberculous  origin ;  the  palsy  is  severe  and  the  loss  of  ability  to 
close  the  eye  very  great. 

Prognosis. — The  prognosis  of  peripheral  palsy  (Bell's)  is  good, 
although  an  absolutely  complete  recovery  often  does  not  take  place. 

In  syphilitic  cases  the  prognosis  is  not  so  good,  though  patients 
may  recover.  In  central  palsies  the  prognosis  is  the  worst,  because 
the  lesion  usually  does  not  disappear.  However,  the  central  cases 
are  from  the  beginning  of  a  mild  type,  and  give  annoyance  mainly 
from  the  secondary  contractures. 

Bell's  palsy  usually  lasts  three  to  five  months.  Occasionally 
there  are  mild  cases  that  get  well  within  a  month.  The  prognosis 
as  to  duration  is  much  helped  by  a  close  study  of  the  electrical  reac- 
tions. In  proportion  as  the  degeneration  reaction  is  complete  and 
persistent  the  outlook  is  bad. 

Treatment. — In  the  acute  peripheral  cases  the  patient  should  be 
treated  promptly  and  thoroughly.  He  should  be  given  a  diuretic 
and  purgative  and  a  blister  should  be  placed  over  the  exit  of  the 
nerve.  This  should  be  followed  or  accompanied  by  hot  fomenta- 
tions. Salicylate  of  soda  in  full  doses  of  twenty  grains  should  be 
given  during  the  first  week.  After  the  paralysis  is  established, 
iodide  of  potassium  is  indicated  in  moderate  doses.  Electricity  is 
to  be  employed  with  care  at  first.  After  a  week  it  may  be  given 
daily  for  five  minutes,  using  the  galvanic  currents  just  strong 
enough  to  contract  the  muscles.  After  three  or  four  weeks,  if  the 
faradic  current  causes  contraction,  it  may  be  used,  otherwise  the 
galvanic  current  is  to  be  continued.  At  the  end  of  a  month  an  ap- 
plication every  other  day  is  sufficient.  At  the  end  of  three  weeks, 
if  the  paralysis  is  severe,  the  corner  of  the  mouth  should  be  drawn 
np  by  means  of  a  bent  hook,  which  is  carried  back  and  fastened  be- 
hind the  ear.  The  patient  should  wear  this  most  of  the  daytime, 
but  not  at  night.  The  object  is  to  take  off  the  strain  caused  by  the 
pulling  of  the  muscles  on  the  sound  side. 

At  the  end  of  a  couple  of  months,  if  secondary  contractures  set 
in,  massage  may  be  tried,  and  the  patient  should  practise  facial  gym- 
nastics daily.  Acupuncture  combined  with  weak  faradic  currents 
and  local  injections  of  strychnine  may  be  tried  in  obstinate  cases. 
If  the  eye  cannot  be  closed  it  should  be  protected  by  a  shade. 


120 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


The  Glosso-Pharyxgeal  ZSTerve. 

Anatomy. — The  glosso-phaiyngeal  nerve  has  motor,  sensory,  and 
visceral  fibres.  The  nucleus  of  origin  of  the  motor  fibres  is  the 
nucleus  ambiguus  common  to  it  and  the  vagus  and  accessory.  The 
sensory  fibres  arise  from  two  small  ganglia  lying  on  the  root  of  the 
nerve,  the  petrous  and  jugular.  The  cells  of  these  ganglia  are  uni- 
polar. The  neuraxon  bifurcates,  and  sends  its  central  filament 
along  the  nerve  root  into  the  medulla,  to  the  gray  nucleus,  known 
usually  as  the  nucleus  of  origin  of  the  glosso-pharyngeal  and  lying 
close  to  the  vagus  nucleus  (Fig.  65) .  Fibres  also  go  to  a  tract  of 
gray  matter  lying  close  to  the  solitary  bundle  and  known  as  the 


rcu  a  xn 


/aru/.aU. 


Fig.  65.— Section  of  Medulla,  showing  nuclei  of  origin  of  the  IX,  X,  XI,  and  XII  cranial 
nerves,    rac.  d..  Ascending  sensory  root  of  IX,  X,  and  XI  nerves. 

ascending  sensory  root  of  the  ninth,  tenth,  and  eleventh  nerves.  The 
nucleus  is  really,  however,  a  terminal  one,  and  is  the  origin  of  sec- 
ondary sensory  neurons  which  send  up  fibres  to  the  brain.  The 
peripheral  filament  of  the  root  ganglia  passes  along  the  nerve  and 
supplies  the  fibres  of  sensation. 

The  nerve  supplies  general  sensation  to  the  tympanum,  tonsils, 
and  pharynx  (in  connection  with  the  vagus)  and  upper  part  of  the 
larynx;  special  sensation  of  taste  to  the  posterior  third  of  the 
tongue,  and  motion  to  the  pharyngeal  muscles  and  oesophagus 
(Kreidl)  in  connection  with  the  vagus. 

The  terminal  filaments  of  the  sensory  taste  fibres  supplying  the 
posterior  two-thirds  of  the  tongue  end  in  fine  fibres  that  pass  into 
the  taste  buds.  There  are  no  special  peripheral  cells  of  taste,  as 
asserted  by  Fusari  and  Panasci. 

Its  cortical  representation  so  far  as  taste  is  concerned  is  in  the 


MOTOR    DISORDERS   OF    SPECIAL    NERVES. 


121 


hippocampal  gyms.  The  nerve  gives  very  sensitive  reflex  fibres  to 
the  pharynx  and  is  important  in  the  reflex  act  of  deglutition;  it 
also  carries  sensations  of  nausea  from  pharyngeal  irritation. 

Motor  Neuroses  of  the  Glosso-Pharyngeal. 

This  nerve  is  rarely  affected  independently  by  motor  troubles. 
Spasm      of     the     pharyngeal  ,  ,„ 

constrictors  occurs  in  general 
disorders  like  rabies,  and  re- 
flexly  in  severe  neuralgia  of 
the  trigeminus.  This  condi- 
tion, known  as  dysphagia,  is 
seen  also  in  hysteria,  and  there 
is  probably  some  spasm  in 
connection  with  the  symptom 
known  as  globus  hystericus. 

Paralysis  of  the  throat 
constrictors  occurs  as  one  of 
the  symptoms  of  glosso-labio- 
laryngeal  paralysis  and  some- 
times indiphtheritic  paralyses. 

The  Pneumogastric  Nerve 
and  the  Accessory  Part 
of  the  Spinal  Accessory. 

Anatomy.  — -  The  pneu- 
mogastric  or  vagus  nerve  has 
two  nuclei  of  origin,  a  motor 
and  a  sensory. 

1.  The  motor  nucleus  or 
nucleus  ambiguus,  which  is  a 
prolongation  of  the  lateral 
horn  of  the  spinal  cord,  lies 
deep  in  the  medulla  and  is  a 
nucleus  common  to  the  vagus 
and  glosso-pharvngeal  (Fig. 
65). 

2.  The  sensory  fibres  arise 
chiefly  from  two  ganglia  that 
lie  on  the  root  of  the  nerve, 
the  jugular  and  plexiform. 
These  bodies  resemble  spinal 
ganglia.  The  cells  are  uni- 
polar and  send  off  a  neuraxon 
which  bifurcates.  The  periph- 
eral fibre  passes  along  the  nerve  and  supplies  it  with  its  sensory 
fibres.  The  central  part  passesup  tothegra]  matter  of  the  floor  of  the 
fourth  ventricle  and  ends  in  the  so-called  sensory  nucleus  (Fig.  65). 


'I'm:   V  u.rs  ash  Sri.s.u.   A.  ■ 
Xkhvk  |  Young). 


122 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


This  nucleus,  however,  is  not  the  real  nucleus  of  origin,  but,  as  in 
the  case  of  the  ninth  it  contaius  cells  which  send  their  axis  cylinders 
or  neuraxons  brainward  and  form  secondary  sensory  neurons.  Fi- 
bres also  go  to  the  ascending  sensory  root  common  to  this  nerve  and 
the  ninth.  It  is  probable  that  some  of  the  cells  of  the  terminal  sensory 
nuclei  of  the  ninth  and  tenth  are  efferent  visceral  cells,  like  those  of 
the  columns  of  Clark,  and  send  out  visceral  fibres.  Both  motor 
and  sensory  fibres  are  chiefly  visceral  in  distribution  and  function. 

The  spinal  accessoky  nerve  is  purely  motor  in  function  (Van 
Gehuchten) .  The  accessory  part  rises  from  the  cells  of  the  nucleus 
ambiguus  and  passes  into  the  trunk  of  the  vagus. 

The  spinal  part  of  the  spinal  accessory  arises  from  the  lateral 
horn  and  outer  part  of  the  anterior  horn  of  the  spinal  cord.  Its 
fibres  of  origin  reach  from  the  first  to  the  third  or  fourth  cervical 
nerves  as  far  as  the  fourth  or  fifth  cervical  roots.  The  fibres  unite 
in  the  cranium  and  pass  out  through  the  posterior  lacerated  foramen 


fWifWfiW/  (%i\ 


WWW 


N     * 


S3     <a 


Fig.  67. — Longitudinal  Section  showing  the  Relative  Position  of  the  Cranial  Nerve 

Nuclei  (Edinger). 


in  the  same  sheath  as  the  vagus.  After  their  exit  from  the  skull, 
they  divide  into  an  internal  and  external  part.  It  is  the  external 
branch  which  contains  the  fibres  of  spinal  origin.  The  internal  part 
contains  the  fibres  from  the  medulla  and  unites  with  the  vagus. 
The  nerve  receives  some  sensory  fibres  from  the  first  and  sometimes 
from  the  second  cervical  nerve.  The  terminal  branches  receive 
motor  fibres  from  several  cervical  nerves.  The  spinal  accessory 
contains  large  and  small  or  visceral  fibres.  The  spinal  part  contains 
only  the  large  fibres. 

The  spinal  accessory  supplies  the  sterno-cleido-mastoid  almost 
exclusively,  but  only  the  upper  part  of  the  trapezius ;  the  rest  of 
this  muscle  is  supplied  by  the  cervical  and  dorsal  nerves.  The 
sterno-cleido-mastoid,  when  innervated,  draws  the  chin  up  and  over 
toward  the  opposite  side.  The  upper  fibres  of  the  trapezius  draw 
the  head  back  slightly  and  down  toward  the  same  side.  Physio- 
logically the  spinal  part  of  the  accessory  nerve  is  one  of  the  motor 
cervical  nerves;  the  accessory  or  medullary  portion  is  part  of  the 
vagus,  and  has  visceral  and  sensory  as  well  as  motor  functions.* 

*  Dees  thinks  that  the  spinal  origin  of  the  eleventh  is  continuous  above 


MOTOR    DISORDERS   OF    SPECIAL   NERVES.  123 

The  vagus  and  accessory  part  of  the  eleventh  together  have  an 
extraordinary  wide  distribution  and  diversity  of  function. 

1.  First  they  contain  motor,  inhibitory,  and  vasomotor  fibres. 
These  fibres  go  to  the  pharynx,  larynx,  trachea,  and  bronchi;  to  the 
oesophagus,  stomach,  small  intestines,  and  spleen. 

2.  Sensory  fibres,  which  go  to  the  occipital  and  transverse 
sinuses  and  dura  mater  of  the  posterior  fossa,  to  the  external  audi- 
tory meatus  in  part,  to  the  pharynx,  larynx,  and  trachea,  and  to 
the  oesophagus. 

3.  Excito-reflex  fibres,  which  go  to  the  lungs  and  heart,  stomach, 
and  to  other  organs  mentioned  as  supplied  by  the  vagus  with  sensa- 
tion. 

These  reflex  fibres  stimulate  or  inhibit  the  vasomotor  centre,  the 
respiratory  rhythm,  and  the  cardiac  rhythm.  They  also  excite  re- 
flexly  deglutition  and  respiratory  movements. 

The  secretory  fibres  go  to  the  respiratory  tract,  oesophagus, 
stomach,  and  pancreas  and  small  intestines. 

Cardio-inhibitory  fibres  go  to  the  heart,  while  reflex  accelerating 
fibres  and  inhibiting  fibres  go  to  the  lungs.  The  accessory  nucleus 
supplies  the  laryngeal  adductors  and  the  cardio-inhibitory  fibres. 


Diseases  of    the   Pxeumogastric  Neuve   and  of  the   Bulbar 
Portion  of  the  Spixal  Accessory. 

These  nerves  are  essentially  visceral  in  character.  Their  dis- 
eases call  for  a  study  of  laryngeal,  pulmonary,  cardiac,  and  ab- 
dominal neuroses,  which  would  bring  us  into  the  domain  of  laryn- 
gology and  general  medicine.  Hence,  despite  their  great  importance, 
I  have  thought  it  best  not  to  try  and  present  them  here.  Some  of 
the  symptoms  are  described  in  connection  with  locomotor  ataxia, 
progressive  muscular  atrophy,  exophthalmic  goitre,  and  angina 
pectoris. 

Xeukosks  of  the  Spinal  Pabt  of  the  Accessories. 

This  is  a  purely  motor  nerve,  and  its  disorders  are  therefore 
spasm  and  paralysis. 

Torticollis  (Wryneck,  Caput  Ousttpum). — Torticollis  is  a 
dis<  ase  characterized  by  clonic  or  tonic  spasm  of  the  muscles  sup- 
plied by  the  spinal  accessory  and  often  of  other  muscles  of  the 
neck.  There  are  several  forms  of  wryneck,  which  must  be  distin- 
guished from  each  other.     They  are:    1,   congenital    wryneck;  2, 

with  the  twelfth,  not  with  the  anterior  nucleus  of  the  tenth.      We  denies  that 
the  medullary  nucleus  sends  fibres  to  the  larynx. 

The  internal  branch  of  the  eleventh  sends  motor  Qbrea  to  the  rectus  posti- 
cus (E.  Keuiak). 


124  DISEASES   OF  THE   NERVOUS   SYSTEM. 

symptomatic  wryneck;  o,  spurious  wryneck,   from   spinal  disease j 
4,  true  spasmodic  wryneck. 

1.  Congenital  wryneck  is  clue  to  some  intra-uterine  atrophy  or 
obstetrical  injury  of  the  stemo-cleido-mastoid.  It  occurs  oftenest 
after  breech  or  foot  presentations.  The  right  side  is  usually 
affected.  There  is  no  spasm  at  all,  but  the  neck  is  fixed  to  one  side 
by  the  shortness  of  the  muscle,  and  also  rotated  to  the  opposite 
side.  The  deformity  becomes  more  noticeable  as  the  child  grows 
older,  because  the  parts  atrophy.  The  atrophy  affects  not  only  the 
shortened  muscles,  but  the  face  on  the  affected  side  (Fig.  68). 

2.  Symptomatic  irnjncrl^  is  usually  due  to  a  rheumatic  myositis, 
and  occurs  chiefly  in  children.      It  may  be  due   also  to  tumors, 


Fig.  68.— Congenital  Wryneck  of  the  Right  Side. 

adenitis,    abscesses,    and  local   syphilitic  disease.     In   these  cases 
there  are  always  pain  and  tenderness  associated  Avith  the  deformity. 

3.  Spurious  wryneck  is  an  apparent  or  real  spasm  of  the  neck 
muscles  due  to  caries  of  the  spine. 

Treatment. — Congenital  wryneck,  if  taken  early,  can  be  cured 
by  tenotomy  of  the  sterno-mastoid  and  subsequent  fixation  of  the 
neck  for  a  time.  When  osseous  changes  have  occurred  perfect  relief 
is  impossible.  Symptomatic  rheumatic  wryneck  is  a  trivial  and 
temporary  affection,  which  needs  only  to  be  palliated  by  hot  appli- 
cations and  saline  purges  until  cure  takes  place. 

Spurious  wryneck  reqirires  suitable  orthopaedic  measures,  such 
as  the  plaster  jacket  and  jurymast. 

4.  Spasmodic  Wryneck. — This  is  a  purely  nervous  disease 
characterized  by  spasm  of  the  muscles  supplied  by  the  spinal  acces- 
sory and  often  of  those  supplied  by  the  upper  cervical  nerves  also. 

Etiology. — Women  are   much    oftener  affected   than   men.     It 


MOTOR    DISORDERS    OF    SPECIAL    NERVES. 


1 25 


occurs  in  early  adult  and  middle  life,  never  in  children  or  old  peo- 
ple.    A  neuropathic  constitution  and  heredity  often  exist. 

The  exciting  causes  are  occupations  which  put  the  lateral  muscles 
of  the  neck  on  a  strain,  depressing  emotions,  physical  shocks  and 
blows,  rheumatic  influences,  and  perhaps  malaria.  Sometimes  no 
cause  can  De  detected.  Reflex  irritations,  perhaps,  exist  in  some 
cases,  but  it  is  difficult  to  find  them. 

Symptoms. —  The  disease  begins  with  slightly  painful  sensations 
in  the  neck,  which  are  soon  accompanied  by  spasm.  The  spasm  is 
at  first  clonic  and  intermittent.  The  sterno-mastoid  is  oftenest  in- 
volved of  single  muscles;  but  the  rule  is  that  the  upper  fibres  of  the 
trapezius  are  also  affected.     The  patient's  head  is  inclined  toward 


Fig.  69.—  Typical  Wryneck   Involving  the  Spinal    Acessory  on  the  Right 
Side  (Walton). 


the  affected  side  by  the  trapezius,  the  chin  is  raised,  and  the  head 
rotated  to  the  opposite  side  by  the  sterno-mastoid  and  trapezius, 
and  this  is  the  typical  position  in  the  disease  (Fig.  69).  If  both 
trapezii  are  affected  the  head  is  pulled  back,  but  tins  is  a  rare  form. 
It iscalled  retro-collic  spasm.  The  eomplexus  and  obliquus  superior 
are  the  only  other  neck  muscles  which  can  rotate  the  head  to  the 
opposite  side.  They  are  supplied  by  the.  upper  cervical  nerves  and 
are  sometimes  involved  in  wryneck.  In  torticollis  the  muscles 
affected  with  spasm  have  a  similar  physiological  function.  Hence 
while  the  sterno-mastoid,  trapezius,  complexus,  and  superior  oblique 
on  one  side  are  attacked  by  the  spasms,  muscles  on  the  other  side 
may  be  at  the  same  time  implicated.  The  opposite  muscle  com- 
monly affected  is  the  splenitis,  which  inclines  the  head  laterally  and 
rotates  it  to  the  same  side.     Probably  the  deep  muscles,  recti  capitis 


126 


DISEASES   OF  THE   NERVOUS   SYSTEM. 


postici,  major  and  minor,  and  the  inferior  oblique,  which  draw  the 
head  back  and  rotate  to  the  same  side,  are  also  at  times  affected. 
The  list  of  muscles  that  may  be  involved  and  their  nerve  supply  are 
as  follows : 


Muscles  usually 
involved. 


Turning  Head  to  Opposite 
Side. 


Steruo-cleido-mastoid. . . 
Upper  fibres  of  trapezius 


Turning  or  Inclining  Head  to 
Same  Side. 


Nerve 
Supply. 


Eleventh. 
Eleventh. 


Muscles     rarely 
involved. 


Superior  obliquus. 
Complexus 


Recti  capitis  postici,  maj., 
min.,  infer.  obliq., 
splenius. 


Cervical. 
Cervical. 


Extreme  rotation  without  much  retraction  of  the  head  would  in- 
dicate involvement  of  the  sterno-cleido-mastoid  and  opposite  splenius. 
Retraction  of  the  head  indicates  involvement  of  both  trapezii. 

The  disease  may  start  in  one  muscle  and  gradually  extend  to 
others,  even  involving  the  facial,  masticatory,  and  brachial  nerves. 
As  it  progresses  the  spasm  becomes  more  constant,  and  finally  it 
may  be  tonic,  never  yielding  except  to  artificial  means  or  during 
sleep.  The  pain  associated  with  the  disease  gradually  decreases. 
The  affected  muscles  hypertrophy,  the  muscles  thrown  into  disuse 
atrophy.  There  is  some  deformity,  in  time,  of  the  neck  and 
shoulders,  but  facial  asymmetry  does  not  occur  in  this  form  unless 
it  begins,  as  is  very  rarely  the  case,  before  maturity. 

The  disease  may  be  complicated  with  or  alternate  with  other 
neuroses.     I  have  known  epilepsy  to  be  associated  with  it. 

Pathology. — The  disease  is  a  neurosis  involving  the  bulbar  and 
cerebral  centres.  The  neuro-mechanism  controlling  the  move- 
ments of  the  neck  is  unstable  and  out  of  control.  Consequently  it 
sends  out  intermittent  and  irregular  discharges  of  nerve  force.  The 
seat  of  the  typical  disease  is  never  in  the  nerve  alone,  probably  the 
cortical  centre  controlling  the  mechanism  of  the  head  movements  is 
at  fault.  The  disease  is  a  degenerative  one,  and  indicates  the 
premature  decay  of  centres  never  perhaps  originally  perfect. 

The  diagnosis  has  to  be  made  from  the  other  forms  of  wryneck 
mentioned.  The  age,  history,  and  fixed  character  of  the  spasm 
serve  to  distinguish  congenital  wryneck.  The  history,  the  pain  and 
tenderness,  and  the  temporary  duration  differentiate  the  rheumatic 
forms. 

The  increased  rigidity  on  passive  motion,  the  pain,  deformity, 
and  other  signs  of  cervical  caries  are  sufficient  to  diagnosticate  ver- 
tebral disease. 

Prognosis. — The  disease  is  not  fatal.     It  generally  reaches  a 


MOTOR   DISORDERS   OF    SPECIAL    NERVES.  127 

certain  stage  and  then  remains  chronic.  In  rare  cases  it  is  cured; 
in  many  others  it  can  be  much  ameliorated.  Cases  occurring  in 
young  people,  in  the  hysterical,  and  in  those  without  a  decided 
neurotic  history  are  the  most  favorable. 

Treatment. — The  drugs  which  are  efficient  are  opium,  atropine  or 
hyoscyamine,  conium,  gelseinium,  valerianate  of  zinc,  asafcetida, 
chloral,  bromides,  arsenic,  and  cocaine.  Of  these,  opium,  atropine, 
gelsemium,  and  zinc  are  generally  the  most  efficacious.  Opium 
must  be  given  with  great  caution.  Atropine  should  be  given  hypo- 
dermically  in  increasing  doses  up  to  intoxication  (gr.  J^-)  (Leszyn- 
sky).  The  galvanic  and  faradic  currents  are  useful  adjuvants  in 
helping  to  relax  the  spasm  and  keep  up  the  nutrition  of  the  muscles; 
but  alone  they  are  not  curative.  Massage  and  stretching  the  neck 
in  a  Sayre  apparatus,  together  with  systematic  exercise  of  the  neck 
muscles,  often  help;  neck  stretching  will  even  sometimes  cure. 
The  only  surgical  measures  to  be  advised  are  nerve  resection,  and 
possibly  the  partial  cutting  of  the  sterno-mastoid  muscle.  A  very 
few  cures  and  many  failures  have  followed  surgical  interference. 

Splints  and  mechanical-fixation  apparatus  do  no  good  as  a  rule. 

Resection  of  the  posterior  branches  of  the  upper  three  or  four 
cervical  nerves,  as  suggested  by  Keen,  has  done  great  good  in  a  few 
cases  (Powers).  Prolonged  rest  for  eight  to  twelve  months  with 
massage  and  exercises  is  on  the  whole  the  most  satisfactory  remedy 

Spasmus  Nutans  {eclampsia  nutans,  nodding  spasm,  salaam 
spasm,  oscillating  spasm). — This  is  a  disorder  occurring  chiefly  in 
children  and  characterized  by  rhythmical  nodding  or  oscillating 
movements  of  the  head. 

Etiology. — The  disease  occurs  in  young  children  who  are  anaemic 
and  badly  nourished.  Dentition,  digestive  disorders,  basilar  men- 
ingitis, gross  disease  of  the  brain,  are  causes.  Sometimes  it  is  only 
a  kind  of  habit  chorea,  and  occasionally  this  habit  continues  during 
life. 

Symptoms. — The  disease  may  come  on  suddenly;  more  rarely  it 
develops  slowly.  The  patient  has  paroxysms  usually  of  a  rather 
violent  character,  lasting  for  minutes  or  hours,  or  even  continuing 
nearly,  all  the  time  except  during  sleep.  The  head  moves  thirty  to 
sixty  times  a  minute  usually,  but  the  motion  may  be  slower  or 
faster.  Movements  of  the  eyes  and  facial  muscles  often  complicate 
the  affection.     The  paroxysm  may  end  in  an  epileptic  attack. 

The  diagnosis  is  easily  made  by  the  symptoms.  The  prognosis 
and  treatment  depend  upon  the  etiology.  I  have  found  useful 
bromide  of  potassium,  hyoscine,  and  syrup  of  iodide  of  iron. 

Paralysis  of  the  Spinal  Part  of  the  Accessory — Eti- 
ology.— The  causes  are  injuries,  caries  of  vertebra,  progressive  mus* 


128  DISEASES    OF   THE   NERVOUS   SYSTEM. 

cular  atrophy,  and  all  forms  of  spinal  disease  reaching  high  up  in 
the  cervical  cord. 

Symptoms. — -When  one  nerve  is  paralyzed  the  head  may  still  be 
held  straight,  but  there  is  inability  to  rotate  it  perfectly.  The 
prominence  of  the  sterno-mastoid  is  absent — atrophy  takes  place. 
No  spasm  of  the  other  muscle  occurs,  and  there  is  no  such  thing  as 
paralytic  torticollis  (Gofers).  The  involvement  of  the  trapezius 
causes  a  depression  in  the  contour  of  the  neck,  especially  noticeable 
on  deep  inspiration.  There  is  some  trouble  in  raising  the  arm,  the 
scapula  is  drawn  away  from  the  spine,  and  the  lower  angle  is 
rotated  inward.  When  both  nerves  are  paralyzed  there  is  great 
difficulty  in  rotating  the  head  or  raising  the  chin.  Paralysis  of  both 
sterno-mastoids  causes  the  chin  to  drop  backward,  while  paralysis 
of  both  trapezii  in  their  upper  parts  causes  the  head  to  drop  for- 
ward. Atrophy  of  the  muscles  attends  the  paralysis  of  the  nerve, 
and  degenerative  reactions  may  be  noted.  The  cervical  nerves  ap- 
pear sometimes  to  supply  the  sterno-mastoid  and  upper  part  of  the 
trapezius  so  much  that  in  disease  of  the  accessories  decided  paralytic 
symptoms  are  absent.  When  both  parts  of  the  spinal  accessory  are 
involved,  dropping  of  the  palate,  dysphonia,  and  rapid  pulse  are 
added  symptoms. 

The  diagnosis  depends  upon  a  thorough  examination  of  the 
motility  of  the  parts. 

The  treatment  is  based  on  a  knowledge  of  the  canse  of  the  dis- 
ease. 

The  Hypoglossus — XII. 

Anatomy. — The  hypoglossal  nerve  arises  from  a  long  and  large 
nucleus  lying  in  the  lower  part  of  the  floor  of  the  medulla  near  the 
median  line  and  to  the  outer  and  ventral  side  of  the  central  canal. 
The  nucleus  is  a  continuation  upward  of  the  anterior  horns  of  the 
spinal  cord  and  is  homologous  with  the  sixth,  fourth,  and  third 
nerve  nuclei  higher  up  (see  Fig.  67).  It  reaches  below  as  far  as  the 
decussation  of  the  pyramids  and  above  as  far  as  the  glosso-pharyn- 
geal  nucleus.  A  second  small-celled  nucleus  lies  just  beneath  the 
nucleus  proper.  Its  cortical  representation  is  in  the  lower  end  of 
the  central  convolutions,  to  which  it  is  connected  by  fibres  that  pass 
into  the  raphe  and  thence  to  the  anterior  pyramids.  Its  fibres  pass 
out  between  the  olivary  body  and  the  anterior  pyramid.  At  its 
origin  it  is  a  purely  motor  nerve;  it  receives  a  few  sensory  fibres 
from  the  cervical  nerves  and  the  vagus.  It  supplies  the  following 
muscles : 

Intrinsic  muscles  of  the  tongue:  superior  and  inferior  longi- 
tudinal and  transverse.  The  extrinsic  muscles  of  the  tongue :  hy- 
oglossus,  genio-hyoglossus,  and  styloglossus.  (The  palato-glossus 
and  Unguals  are  supplied  by  the  fifth  and  seventh  cranial  nerves 


MOTOR   DISORDERS   OF    SPECIAL   NERVES.  129 

respectively).  The  depressors  of  the  hyoid:  the  thyro-hyoid  and, 
•with  the  cervical  nerves,  the  sterno-hyoid  and  sterno-thyroid.  The 
elevator  of  the  hyoid :  genio-hyoid.  It  is  also  thought  to  send  fibres 
to  the  oral  muscles  (Tooth). 

The  hypoglossal  nerve  is  concerned  in  the  movements  of  the 
tongue  and  in  fixing  or  depressing  the  hyoid  in  mastication  and 
deglutition.  When  diseased,  therefore,  speech  and-  deglutition  are 
affected.  The  small  nucleus  of  the  nerve  is  thought  to  control  the 
finer  lingual  movements  of  articulation. 


Motor  Neuroses  of  the  Hypoglossal  Nerve. 

The  diseases  of  this  nerve  consist,  of  lingual  spasms,  lingual 
palsy,  and  lingual  hemiatrophy. 

Lingual  spasms  take*  part  in  the  disorders  of  articulation,  help- 
ing to  cause  stuttering  and  speech  cramps.  Such  troubles  are  often 
developmental  in  origin  and  belong  to  the  habit  choreas  or  convulsive 
tics. 

Stuttering  is  a  spasmodic  disorder  in  which  the  tongue  muscles 
are  involved,  preventing  the  proper  enunciation  of  words  and 
sentences. 

Stammering  is  an  imperfect  articulation  due  sometimes  to  dis- 
ease or  defect  in  the  hypoglossal  nerve  and  its  muscles.  It  is  not  a 
spasm. 

The  letters  that  are  cftenest  badly  pronounced  are  E,  L,  and  S. 
Lisping  is  a  form  of  stuttering.  Stammerers  are  sometimes  called 
the  "RLS  people." 

Aphthongia  is  the  name  given  to  a  form  of  spasm  occurring  in 
speakers  and  similar  in  nature  to  writer's  cramp. 

Clonic  lingual  spasm  occurs  in  chorea,  hysteria,  and  during  the 
attacks  of  epilepsy.  Unique  cases  of  this  spasm  also  occur  from 
reflex  irritation  or  central  nervous  disease. 

Tun  it'  lingual  spasm  occurs  in  hysteria,  and  sometimes  as  an  in- 
dependent affection  due  to  unknown  causes,  generally  those  of  a 
debilitating  and  nervously  depressing  character.  Keflex  irritation 
may  be  a  cause. 

Lingual  paralysis  (glossoplegia)  is  usually  one  of  the  symp- 
toms of  glosso-labio-laryngeal  pals}-.  It  may  be  caused  by  a  bilateral 
or  even  a  single  lesion  in  the  cerebral  hemispheres  The  condition 
is  then  known  as  pseudo-bulbar  paralysis.  Diseases  of  the  medulla 
and  of  the  nerve  itself  may  cause  the  paralysis. 

The  paralysis  may  be  either  unilateral  or  bilateral.     The  symp- 
toms are  an  impairment  of  speech  and  of  swallowing.      Fuller  de- 
tails will  be  given  under  the  head  of  Bulbar  Palsy. 
9 


130  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Progressive  Lixgual  Hemiatrophy. — A  progressive  hemi- 
atrophy of  the  tongue  sometimes  occurs.  It  is  analogous  in  all  re- 
spects to  facial  hemiatrophy,  with  which  it  is  sometimes  associated. 
It  is  probably  due  to  a  low  grade  of  degenerative  neuritis  of  the 
nerve.     It  is  very  rare. 


PLATE   II 


NERVOUS    DISEASES. 
Dana. 


[(a)  interior  e 


i-rb-s  (iTiteivalafinn  of  the  -  ili:nT  i'. 
""  -  pupil  for  con' 
■•  palpebra'  s 


rot'  the  pupil  i"nv  .-t nit r;n-li. -f i  .>!    tin-  pupil.' 


t>'iupi->i';il.  pterygoid,  ruylo-hyoid- 


.ud  levator  veli  palati.    Secretion 
External  rectus  of  the  eye  (outward  movement). 

J'lii'    mimic,    la.c    muscles;      tumtal.    nrbiclllar    "f    til*: 
I'latysiu.l.      (Il   III"  ill's,  stapedius,    pl.'SlcrU'rdlLM.-Lfie, 

Palate  uiiiM'iilature? 

I'll i>»:tt.  imisriil.il in'.'    [constrictors),  cm-o-tliynud, 
TiiiiLiu-:  musculature,  .-teriio-hyuid,  thyreoid*'!. 

useuhiture     (voice    formation |,    palate,  phai 


gastric,  tensor 


1  mouth;    zygomatici,   mental; 


Nasal  secretions.    Tears 

of  gastric  juice.    Movements 
|  heart  ami  Ihi  atlm 
goal  musculature  (with  the 


ngi— sterno-el-  t<l"-ma-0>id  (drawing  the  In  ml  lati-i'itlly  ami  neddmgi      Trap. 


[•  luck  luiis. 'li-s.    Trap- 


a  part  (movement  of  head  and  throat), 


(■interior  adduction  <>t  the  n 

(lung  thoracic  i 


ni.  pectnr.ilis  miniir,  suticlavius- 

i  l-it l.i  i  (draw  -.  t h<:-  :-,'.ii.iii.i   inward  and  up- 

1  lixi  s   I.lo.-  slwuLlcr  blade  iiud   draw-  tip-* 


iLipn'l:!',  rhomboids  (dorsal  mrves  uf  the  scapula)  (di 
erratus  anticus  luajnr  il"itg  thoracic  nerve)  fixe     " 
COUJuui'ti'i:i  with  tin-  ;i nn  ii l>"\  i   l In-  horizontal. 
Snpraspinatus  (raises  and  rolls  the  arm  outward),  infraspinatus,  teres  minor  (rolls  outward). 
Subscapulars ,  teres  major  (rotates  inwardi,  latissiunis  dorsi  (adducts  the  arm  and  draws  i 6 
•IS.    Deltoid  (raise;  the  arm  to  horizontal.)  [backward). 

Biceps    (flexor  of   forearm    and  supinatori.    braehialis    amicus    ilb-xor  ot'    ton-arm),   coraco- 
brachialis. 

Flexor  omirmn  us  digit"  mm  (radial  pm-tinm  ibem!:-  tie   n-tiLiuiil  phalang—  >,  dcxnrlimgus  pol- 
len! phalanx),  fb-xor  carpi   radial  is.  pr,  niat>>r  radii  I'  n  .-,  and  .  |U,nlr.iin-.  pa  I  man-  loiigu.s, 
::C  in  ;  -:■)■  ■.  i   ■;  .j  ii  m-  in  -  ,-t  ihimiVi  Hi  x  i  In-  primary  plialaii:_'-s  and  >  xt-  nl  tlm  l-rtuinal  pha- 
langes), liuubricales  1,  2,  seldom  :i  (flex  tin-  peripheral  phalange-  and  extend  simultaneously 
the  terminal  phalanges). 
21.     Triceps  (e\ttm-or  o!    tup-arm  I,  radial   portion  of  brachial^   aiitii'us.  supinator  bmgus!   ■  ll-  v.  sj 
sarin  1,  extensor  eommnuis  digiturum  (extensor  of  the  pinple-ra]  pbalan- 
3— abductor  pidheis.  -upinat.u'  breyi-,  e\  tensor  .-arpi  r.eliahs  and  ulnar  is. 
r   j..-..-  uiel  u.-  diirit-'nnn   miliar  port  bun,  ><■■■  L'n      l"b-\or  .  arpi  lilnan.-,  hep  'thenar,  inter 
(flex  the  peripheral  phalanx),  lumbriuales  bland  4 1,  tee  :M,  adductor  pollicia. 

Deep  back  muscles. 

Iiitcreostal  muscles. 

I'eep  back  mu-eb-s  (extensor  of  trunk). 

Intercostal  muscles. 

UBcles,  abdominal  muscles  (recti. s,  external  oblique)  (compressor  of  abdomen). 
Back  (lumbar)  muscles. 

abdominal,  internal  'Odium.-  (compressor  of  abdomen). 


oblique. 

1  obturator,  adductor  of  thigh,  i 

lumbar  pie: 

"    >leg),e     ' 

i:i-'llll- 

(abdui 


jilifi  (adductor), 
raws  up  the  thigh,  fl 


r  (abductors 


the  trunk),  Quadriceps  (ei- 
rinre  femoris,  pyriformis,  obturator 

:  the  log),  quadriceps  femoris  (ad- 


s  the  inner  border  of  foot),  peronei  (raise  outer  border  of  foot), 
s  (plantar  flexion  of  the  foot),  flexor  digiti,  tibialis  posticus. 


Small  muscles  of  foot  (flexor  br 

41.  Levator,  internal  sphincter  ani,  sphincter  vesica?, 

42.  Sphincter  ani,  perineal  musculature,  bulhi  cavernosi,  t 
1  sphincter  ani. 


LOCATION    OF    THE  SEGMENT 
Sensibility.  Hottltty. 


Explanation  of  the  Abbreviations.— tr.  olf  =  olfactory  tract; 
lateral  geniculate  body;  p.,  r.,  cr.^mt..  A.,  represent  approximately  the  lo- 
cation of  the  reflex  centre^;  the  pupillary  reflex  (p.),  for  the  respiratory  re- 
flex (»*.).  for  the  cremnster  reflex  (cr.),  patellar  reflex  Cpaf),  and  the 
Achilles  reflex  (-4.).  The  centres  for  the  bladder  and  rectum  in  the  sacral 
cord  are  represented  by  circles;  likewise  the  centres  for  erection  and  ejacu- 
lation. The  centre  for  contraction  of  the  uterus  is  probably  likewise  in  this 
vicinity  (Jakob). 


CHAPTEK  IX. 

NEUROSES   OF   THE   MOTOR   SPINAL   NERVES. 

Anatomy  and  Physiology. — The  spinal  nerves  arise  from  the 
spinal  cord  by  two  roots,  anterior  and  posterior.  These  roots  unite 
outside  the  spinal  canal  to  form  mixed  nerves.  The  mixed  nerves 
divide  and  go  to  their  various  destinations.  There  are  thirty-three 
pair  of  spinal  nerves,  viz. : 

Cervical 8 

Dorsal 12 

Lumbar 5 

Sacral 5 

Coccygeal 3  (all  rudimentary). 

33 

The  last  two  coccygeal  nerves  are  microscopic  in  size,  and  the  first 
pair  is  very  small,  so  that  practically  there  are  but  thirty  sets  of 
spinal  nerves. 

The  posterior  roots  are  closely  connected  with  ganglia  lying  in 
the  intervertebral  canal,  and  called  intervertebral  ganglia,  or  ganglia 
of  the  posterior  roots.  These  ganglia  are  the  real  origin  of  the  great 
majority  of  the  fibres  of  these  roots.  The  mixed  nerve  is  connected, 
by  fibres  that  come  chiefly  from  the  anterior  root,  with  the  sympa- 
thetic or  prsevertebral  gauglia.  The  distribution  of  the  spinal 
nerves  is  also  shown  in  Fig.  70. 

For  the  purpose  of  conveniently  studying  the  diseases  of  the 
spinal  nerves,  we  divide  them  into  six  different  groups,  each  having 
a  somewhat  definite  work  to  do.  These  groups  are  shown  in  the 
accompanying  table. 


Strands  of  Spinal  Nerves. 

Distribution. 

Group     I. 

Upper  four  cervical. 

Occipital  region,  neck. 

II. 

Lower   four   cervical   and 
first  dorsal. 

Upper  extremities 

"       III. 

Upper  six  dorsal. 

Thoracic  wall. 

tt       IV. 

Lower  six   dorsal   except 

Ali'lominal  wall,  upper  lum- 

last. 

bar,  upper  lateral  thigh 
surface. 

V. 

Twelfth  dorsal,  four  lum- 

Lumbar  region,   upper  glu- 

bar. 

teal,  anterior  and  Inner 
thigh  and  knee. 

"      VI. 

Fifth     lumbar     and     five 

Lower     gluteal,      posterior 

sacraL 

thigh,  leg. 

associated  Ganglia  of 
s>  mpal  hetlc. 

First  cervical. 
Second  and  third  cer- 
vical, first  dorsal. 
First  to  sixth  dorsal, 

Fifth  to  twelfth  dorsal. 


First  to  fourth  lumbar. 
Firstto  fifth  sacral. 


Group  I.  The  Uj tki;  O.kyical 

includes  the  first  four  of  the  spinal  nerves.     These  divide  into  an- 
terior and  posterior  brandies.     The  posterior  branches  supply  the 


132 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


muscles  and  skin  of  the  back  of  the  neck  and  the  occiput.  The 
principal  nerves  are  the  suboccipital  and  the  great  occipital.  The 
anterior  branches  form  the  cervical  plexus.  Its  principal  branches 
are  the  auricularis   magnus,  occipitalis  minor,  and  phrenic.     The 


Fig.  n.— Showino  the  Formation  or  the  Mixed  Nerves  and  the  Mode  op  Origin   op 
the  Motor  and  Sensory  Parts. 


special  distribution  of  the  nerves  is  shown  in  the  table  facing 
Fig.  70. 

The  upper  cervical  nerves  supply  motion  to  the  muscles  which 
rotate  the  head  and  draw  it  back  and  sideways. 

One  branch,  the  phrenic,  supplies  the  diaphragm ;  other  muscles 
assist  in  fixing  the  thorax  in  forced  inspiration.  They  innervate 
some  of  the  hyoid  and  thyroid  muscles,  but  have  no  influence  on 
phonation  or  deglutition.  This  group  of  nerves  is  in  close  connec- 
tion centrally  with  the  trigeminal  nerve,  whose  descending  root 
reaches  down  into  the  cervical  cord.  The  fibres  to  the  scalp  and 
face  also  anastomose  with  the  trigeminus  in  their  peripheral  distri- 
bution to  the  scalp  and  chin. 

The  diseases  of  the  upper  cervical  group  are  spasms,  paralyses, 
and  neuralgias. 

Spasmodic  Diseases. — Torticollis  may  be  limited  to  the  cer- 
vical nerves,  as  has  been  shown. 

Tonic  spasm  causing  a  rigid  neck  is  a  frequent  symptom  of 
meningitis,  and  forms  part  of  epileptic  and  other  convulsions. 


NEUROSES    OF   THE    MOTOR    SPINAL   NERVES.  133 

In  oscillatory  and  rotatory  spasms  the  cervical  nerves  are  in- 
volved. 

In  some  forms  of  stuttering  the  phrenic  nerve  is  involved  in  a 
clonic  or  tonic  spasm. 

Hiccough  is  a  clonic  spasmodic  disorder  of  the  phrenic  nerve. 
It  is  usually  due  to  gastric  disturbance,  with  flatulent  distention  of 
the  stomach. 

When  chronic,  it  is  caused  by  hysteria,  neuritis,  diaphragmatic 
pleurisy,  or  some  pressure  upon  the  nerve  in  its  course.  I  have 
seen  cases  in  which  it  was  probably  a  pure  spasmodic  neurosis. 
Ordinarily,  hiccough  can  be  stopped  by  simple  carminatives  like 
spirits  of  chloroform  or  lavender.  In  obstinate  cases  in  which  no 
known  cause  can  be  found,  pilocarpine,  hyoscine,  and  bromides  are 
useful.  Counter-irritation  along  the  neck  helps  some  cases.  A 
most  effective  measure  is  to  lay  the  patient  supine  over  a  thick 
bolster  so  that  the  head  hangs  back  and  the  thorax  arches  up.  An 
injection  of  morphine  and  atropine  promptly  stops  some  cases. 

Paralyses  and  Atrophy. — The  cervical  muscles  arc  paralyzed 
in  progressive  muscular  atrophy,  in  pachymeningitis  hypertropliica, 
and  occasionally  in  vertebral  and  pheripheral  disease  or  injury. 
Some  deformities  and  weakness  in  head  movements  result,  but  the 
most  serious  consequence  is  involvement  of  respiration  through  palsy 
of  the  phrenic. 

Paralysis  of  the  Phrenic  Nerve — Etiology. — Such  pa- 
ralysis may  be  due  to  disease  or  injury  of  the  cervical  cord  and  also 
to  peripheral  disease,  to  which  the  nerve  is  somewhat  liable  owing 
to  its  long  course  through  the  anterior  mediastinum. 

Pleurisy,  peritonitis,  mediastinal  tumors,  rheumatic,  and  toxic 
influences,  and  hysteria  are  among  the  special  causes  of  phrenic 
paralysis.  Spinal-cord  disease,  such  as  tabes,  acute  ascending 
paralysis,  and  surgical  injuries  are,  however,  the  commonest  eti- 
ological factors. 

Symptoms. — In  diaphragmatic  paralysis,  if  bilateral,  as  is  usually 
the  case,  there  is  either  no  movement  of  the  abdomen  or  the  epigas- 
trium and  hypochbndrium  are  drawn  in.  On  slight  exertion  there 
are  dyspnoea  and  increase  of  respiration. 

Diagnosis. — If  no  other  muscles  than  the  diaphragm  are  involved, 
the  cause  is  probably  in  the  trunk  of  the  nerve.  Inflammatory 
disease  of  the  diaphragm  may  cause  a  paralysis  which  is  recognized 
by  its  painful  character  and  the  febrile  reaction. 

Treatment. — This  is  to  be  guided  by  the  cause.  It  need  only  be 
said  that  there  is  a  motor  point  in  the  neck  where  by  careful  elec- 
trization one  can  get  a  contraction  of  the  diaphragm  (see  Fig.  .'!<>,  J'>). 
In  paralysis  of  the  phrenic  this  fact  should  be  borne  in  mind. 


134 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


Group  II.     The  Lower  Cervical  Nerves  and  Brachial 

Plexus. 

Anatomy  and  Physiology. — The  anterior  branches  of  the  lower 
four  cervical  nerves  and  first  dorsal  nerve  unite  to  form  the  brachial 


Fig.  72.— Showing  the  Distribution  of  the  Sensory  Nerves  of  the  Skin. 


KEUROSES   OF   THE   MOTOR   SPINAL   NERVES. 


135 


plexus.  This  gives  off  shoH  nerves  to  the  shoulder  aud  trunk  and 
long  nerves  to  the  arm. 

The  mode  of  formation  of  the  brachial  plexus  is  shown  in  the 
diagram  (Fig.  73).  It  is  in  accordance  with  the  descriptions  of 
Walsh  and  Allen.  The  short  or  upper  branches  supply  the  shoulder 
and  iutercostal  muscles.  The  long  or  lower  branches  supply  the 
arm  and  hand.  The  neurologist  needs  to  know :  (1)'  the  muscular 
distribution  of  each  nerve  and  the  function  of  the  muscle;  (2)  the 
cutaneous  sensory  distribution;  and  (3)  the  level  of  origin  of  the 
nerves. 

The  previous  figure,  Fig.  70,  and  table  give  these  points,  and  will 
be  found  useful  for  study  and  reference.  They  are  based  upon  the 
investigations  of  Ferrier  and  Yeo,  Thorburn,  and  also  on  Abbe' s  and 
my  own  experiments. 

The  Arrangement  of  the  Brachial  Plexus. — It  is  made  up  of  three 
nerve  trunks,  which  in  turn  make  up  three  cords,  these  cords  giving 
off  various  branches,  thus : 


Trunk     from     sixth    and 
seventh  cervical  roots 


|  forms  outer  cord,  which 
f      gives  off 


Trunk  from  eighth  cervi-  )  forms  inner  cord,  which 
cal  and  first  dorsal  roots   f      gives  off 


(  Ext.  ant.  thoracic. 
-  Musculocutaneous. 
(  Outer  head  median. 

f  Inner  head  median. 

|  Ulnar. 
{  Int.  cutan. 

j  Int.  ant.  thorac. 

^  Intercost.  -hum. 


Trunk 
seventh 
vical  and  first  dorsal 


from    fifth,    sixth,  )  f  nnsterior  cord    which  \  ^^^ipu\&T. 

th,  and  eighth  cer-  .torms  posterior  cord,  which  )  Circumflex. 

Slves  off  Musculo-spirah 


The  following  table  shows  the  origin,  muscular  distribution,  and 
effect  of  paralysis  on  the  motor  but  not  on  the  sensory  nerves. 
This  latter  is  indicated  in  Figs.  72  and  32. 


Nerves  and  Roots  of  Origin. 


Muscular 
Distribution. 


Function  as  Shown  by  Effect  of 
Paralysis. 


Posterior  thoracic. 
Fifth  and  sixth  cervical. 


Circumflex. 

Fifth,     sixth,     seventh     and 

eighth  cervical. 
Suprascapular. 


Subscapular,  short. 
Fifth  and  sixth  cervical. 

Subscapular,  long. 

Fifth,     sixth,     seventh,     and 

eighth  cervical. 
Anterior  thoracic. 

Musculo-cutaneous. 
Fourth  and  fifth  cervical. 
Musculo-spiral. 


Serratus  magnus. 


Deltoid. 
Teres  minor. 

Supraspinatus. 


Infraspin  a  t  u  s   and 

teres  minor. 
Subscapulars. 
Teres  major. 

Latiss.  dorsi. 


Pectoralis  major. 

Biceps  and  brachialis 

anticus. 
Triceps. 


Posterior  edge  of  scapula  is  rotated 
out  when  arm  is  raised  and  carried 
forward. 

Weakening  of  elevation  of  shoulder 
and  of  inspiration. 

Loss  of  power  to  raise  arm. 

Weakened  powa  toraise  arm;  head 

of  humerus  tends  to  fall. 
Loss  of  abductors,  motion  forward 

an<l  inward  rotation  of  bumerua 
Loss  of   rotation  of  humerus  out- 
ward. 
Weakens  inward  rotation  of  arm. 
Weakens    power    of    elevating 

shoulder. 
Weakens  power  to  depress  shoulder 

and  to  pull  arm  backward  and  to 

si.liv 
i.oss  of  power  to  pull  arm  down  and 

forward  and  to  shrug  the  shoulder. 
Loss    of    flexion    of    forearm    aud 

weakness  of  Inspiration. 

'.tension  of  forearm. 


136 


DISEASES    OF   THE   NERVOUS   SYSTEM. 


Nerves  and  Roots  of  Origin. 


Muscular 
Distribution 


Function  as  Shown  by  Effect  of 
Paralysis. 


Fourth,    fifth,  sixth,  seventh, 
and  eighth  cervical. 


Median. 

Fifth,     sixth,     seventh,    and 
eighth  cervical. 


Ulnar. 

Eighth  cervical,  first  dorsal. 


Supinatores. 

Extensor  carp.  rad. 
Extensor  carp.  uln. 

Extensor  comni.  digit. 

Extensor  p.  i.  pollie. 
Extensor  s.  i.  pollie 
Extensor     oss.     met. 

pollie. 
Prouatores. 
Plexor  carp.  rad. 
Flexor  sublim.  dig. 
Flexor   profund.   dig. 

radial  half. 
Two  lunibricales. 
Abductor  pollie. 
Flexor  pollie. 
Flexor  carp,  ulnar. 


Flexor  profund. 
ulnar  half. 


dig. 


Interossei. 
Two  lumbricales. 
Flexor  minor  digit. 
Abductor  pollicis. 
Inner    half    of  flexor 
brev.  pollicis. 


Loss  of  supination. 

Extension  of  wrist  lost  except  when 
fingers  are  flexed ;  lateral  devia- 
tion. 

Impaired  extension  of  first  pha- 
langes and  wrist. 

Impairment  of  extension  of  thumb. 


Loss  of  pronation. 

Weakened  flexion  of  wrist. 

Weakened  flexion  of  second  and 
third  phalanges  of  first  and  sec- 
ond fingers. 

Loss  of   abduction   and  flexion   of 

thumb. 
Weakened  flexion  Of   wrist;   radial 

deviation. 
Weakened   flexion   of    second    and 

third     phalanges    of     third    and 

fourth  fingers. 
Loss  of   flexion  of  first  phalanges 

and  of  extension  of   second  and 

third. 


Diseases  of  the  Lower  Cervical  Nerve  Group  and  the 
Brachial  Plexus. — The  nerves  of  this  group  are  subject  to  the 
pathological  disturbances  common  to  all  nerves.  I  shall  describe 
them  from  the  clinical  side,  which  gives  the  following  disorders : 


Paralyses 


r  Combined  arm  palsies. 
J   Upper-arm  type  or  Erb's  palsy. 
Lower-arm  type. 
Paralysis  of  individual  nerves. 
Spasmodic  Disorders.  ■{  Occupation  neuroses. 

(  Brachial  neuralgia. 
Sensory  Disorders.   -]  Digital  neuralgia. 
(  Numb  hands. 

Secretory,       Trophic,  \ 
and  Vasomotor  Dis-  -  Neurotic  wdema. 
orders.  ) 

Spasmodic  Disorders  of  the  Arm. — The  arms  and  hands  are 
especially  subject  to  tremors,  choreic  and  other  spasmodic  move- 
ments. The  only  spasmodic  disorders,  however,  which  may  be  said 
to  be  especially  located  there  are  writer's  cramp  and  allied  occupa- 
tion neuroses.     These  are  described  elsewhere. 

Brachial  Paralyses,  Arm  Palsies. — These  occur  as  com- 
bined or  total-arm  palsies,  upper-arm  and  lower-arm  types,  and 
paralyses  of  single  nerves. 

Combined  paralysis  of  the  brachial  nerves  is  a  condition  in 


NEUROSES    OF   THE    MOTOR    SPIXAL   NERVES. 


137 


which,  all  or  nearly  all  the  portions  of  the  plexus  and  its  brunches 
are  involved.  Total  arm  palsies  make  up  about  six  per  cent,  of  all 
peripheral  paralyses,  and  are  about  one-fifth  as  frequent  as  single- 
nerve  paralyses. 

Etiology. — They  occur  oftenest  in  men,  but  are  not  rare  in  in- 
fants, being  then  due  to  injuries  during  parturition.  After  infancy 
they  are  most  frequent  in  early  and  middle  life. 

The  exciting  causes  are  obstetrical  and  other  injuries;  deep- 
seated  inflammations  and  tumors;  shoulder  dislocations;  primary 
neuritis;  crutch  and  other  forms  of  mechanical  compression;  func- 


«£»    OT  MIACSTHESU 


Fig.  73.— Illustrating  the  Formation'  of  the  Brachial  Plexus;  also  the  Involvement 
op  the  Plexus  in'  Degenerative  Neuritis  (Lksztkskt), 

tional  palsies,  from  overwork   and  hysteria;  in   rare   cases,  spinal- 
cord  and  brain  disease. 

The  symptom*  vary  with  the  severity  and  extent  of  the  lesion. 

With  regard  to  severity,  there  are  three  degrees.  In  the  Hist 
there  is  simply  a  transient  palsy,  due  to  lying  too  long  on  the  arm. 
The  arm  feels  heavy,  numb,  and  "asleep."  In  a  few  minutes  or 
hours  this  palsy  disappears.  In  the  second  degree  the  nerves  are 
so  much  compressed  as  to  be  mechanically  injured.  If  the  patient 
has  been  drinking  hard,  even  moderate  pressure  may  set  up  an  in- 
flammatory or  destructive  process  that  leads  to  quite  a  serious  palsy. 
In  the  third  degree  the  nerves  are  actually  cut  or  torn  aero--,  or  so 
compressed  as  to  lose  their  anatomical  integrity. 

The  resulting  symptoms  are  those  common  to  all  nerve  injui 
viz.,  paralysis,  wasting,  ehanges in electrieal  reaction  of  the  inufi 
Pain,  tenderness,  anaesthesia,  trophic,  secretory,  and  vasomotor  dis- 
turbances are  also  present  in  varying  degree. 

The  distribution  of  the  paralysis,  atrophy,  and  sensory  disturb- 


138 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


ance  depends,  of  course,  upon  the  arm  nerves  chiefly  involved. 
The  cuts  and  table  will  enable  one  to  see  in  any  case  where  the 
trouble  is  localized. 

There  are  three  common  symptoms,  however,  of  which  it  is  often 
very  important  to  analyze  the  cause.  These  are  the  loss  of  power 
for  elevation  of  the  arm  and  for  flexion  and  extension  of  the  forearm. 

Flexion  of  the  forearm  is  performed  by  the  biceps  and  brachialis 
anticus,  and  is  helped  by  the  supinator  longus.     These  muscles  are 


Fig.  74.— Upper- Arm  Palsy  op  Left  Side. 


supplied  by  the  musculo-cutaneous  nerve,  except  the  supinator, 
which  is  supplied  by  the  museulo-spiral.  Hence  when  a  person 
cannot  flex  the  forearm,  the  musculo-cutaneous  is  chiefly  affected. 

Extension  of  the  arm  is  done  by  the  triceps,  which  is  supplied 
by  the  museulo-spiral. 

Elevation  of  the  Arm  Outward. — Inability  to  raise  the  arm  is  the 
common  and  striking  symptom  in  combined  brachial  palsies.  The 
arm  is  raised  by  a  number  of  muscles.  The  deltoid  acts  first  and 
most,  but  it  can  raise  the  arm  only  to  a  right  angle.  It  is  supplied 
by  the  circumflex  nerve  from  the  posterior  cord  of  the  plexus. 
Viter  the  arm  is  raised  to  a  right  angle,  it  is  further  elevated  by 


NEUROSES   OF   THE    MOTOR    SPINAL   NERVES. 


139 


rotating  the  scapula,  and  this  is  clone  chiefly  by  the  middle  part  of 
the  trapezius  (lower  cervical  and  upper  dorsal  nerves)  and  by  the 
serratus  magnus,  supplied  by  the  posterior  thoracic  nerve.  A 
number  of  other  muscles  combine  to  strengthen  elevation  of  the 
shoulder,  but  this  action  can  be  abolished  only  by  paralysis  of  the 
deltoid  or  trapezius  and  serratus  mangus. 

The  diagnosis  of  these  cases  involves,  first,  the  consideration  of 
the  seat  of  the  lesion  and  the  special  nerves  involved;  next,  that  of 
the  nature  of  the  lesion.  A  recognition  of  the  seat  of  the  lesion 
and  of  the  special  nerves  involved  depends  entirely  upon  the  study 


Fig.  75.— Lower-Arm  Palsy  due  to  Multiple  NErnRrrrs. 

of  the  distribution  of  the  palsy  and  of  the  atrophy  and  sensory  dis- 
turbance. It  is  important  to  determine  whether  one  is  dealing  with 
a  total-arm  palsy,  an  upper-arm  type  (Erb's  palsy)  or  a  lower-arm 
type. 

In  ErVs  palsy  there  is  involvement  of  the  deltoid,  biceps,  bra 
chialis  anticus,  and  supinator  longus,  with  at  times  paralysis  of  the 
supinator  brevis,  and  even  of  all  the  muscles  supplied  by  the  median 
nerve.  The  lesion  is  either  in  the  cord  formed  by  the  fifth  and 
sixth  cervical  nerves  or  a  little  lower  in  the  brachial  plexus,  where 
the  fibres  supplying  the  nmsculo-spiral,  circumflex,  and  musculo- 
cutaneous lie  close  together.  At  all  events,  the  lesion  involves 
the  central  parts  and  upper  cords  of  the  plexus.  The  arm  hangs 
by  the  side  and  the  forearm  cannot  be  flexed  (Fig.  74). 

In  the  lower-ami  type  the  triceps,  the  flexors  of  the  wrist,  the 


140  DISEASES   OF   THE   NERVOUS    SYSTEM. 

pronators,  the  flexors  and  extensors  of  the  fingers,  and  the  hand 
muscles  are  involved.  The  arm  can  be  raised  and  the  forearm 
flexed  and  supinated,  but  the  hand  is  useless  and  the  extension  of  the 
forearm  is  impossible.  The  lesion  here  involves  chiefly  the  nerves 
from  the  seventh  and  eighth  cervical  and  first  dorsal  roots  (Fig.  75). 

If  the  lesion  is  in  the  nerve  there  will  be  atrophy,  changes  in 
electrical  reaction,  sensory  disturbances,  and  often,  if  there  is  neu- 
ritis, pain  over  the  nerves.  The  reflexes  will  be  lessened  or  absent. 
If  the  lesion  is  in  the  spinal  cord,  symptoms  in  other  parts  of  the 
body  will  be  present,  or,  if  not,  there  will  be  no  sensory  disturbance, 
as  in  an  arm  palsy  from  anterior  poliomyelitis.  In  rare  cases  arm 
palsies  may  be  caused  by  spinal  tumors  or  a  local  meningitis,  in 
which  case  diagnosis  is  difficult. 

The  upper-arm  t<jpz  and  lower-arm  type*  palsies  are  caused  by 
much  the  same  factors  as  the  combined  palsies;  their  symptoms 
have  been  indicated  above.  The  upper-arm  type  is  especially  fre- 
quent in  infants  and  constitutes  one  of  the  obstetrical  paralyses. 
It  may  in  some  cases  be  due   to  injury  or    hemorrhage    in    the 

cord. 

The  prognosis  is  usually  good.  Nearly  all  these  cases  get  well, 
the  duration  of  the  incapacity  being  from  two  or  three  months  to  a 
year.  Even  in  the  severest  cases  recovery  is  possible  after  one  or 
two  years.  If,  however,  the  nerves  are  torn  across  and  the  ends 
widely  separated,  recovery  is  doubtful  unless  an  operation  is 
promptly  done. 

The  treatment  consists  in  electrical  applications,  mechanical  sup- 
port, with  potassium  iodide  internally  and  abstinence  from  alcohol. 
Local  injections  of  nitrate  of  strychnine  are  useful,  and  massage 
should  be  used  if  it  can  be  applied  carefully. 

In  brachial  palsies  due  to  severe  injuries,  dislocations,  frac- 
tures, etc.,  in  which  there  is  evidence,  from  the  extreme  atrophy 
and  absence  of  electrical  reaction,  that  the  nerve  is  entirely  cut 
across  and  that  the  ends  are  not  in  apposition,  a  surgical  operation 
is  stringently  needed.  The  nerves  should  be  exposed  and  the  ends 
brought  as  near  together  as  possible.  Decalcified-bone  tubes  or 
sterilized  macaroni  may  be  used  to  give  a  passage  for  the  central  end 
to  grow  into  the  peripheral.  In  these  cases,  however,  it  must  be 
remembered  that  the  two  ends  do  not  unite;  but  the  central  end 
grows  down  in  the  tract  of  the  old  degenerated  peripheral  stem. 

A  peculiar  form  of  combined  nerve  palsy  sometimes  occurs,  due 
apparently  to  a  primary  brachial  neuritis,  It  begins  in  the  plexus 
and  involves  first  the  nerves  of  the  upper  cervical  roots.  It  may 
extend  down  and  involve  the  ulnar,  median,  or  musculo-spiral. 


XEUR0SE8   OF    THE    MOTOR    SPINAL    XERVES.  141 

It  occurs  in  adult  men  generally  and  in  those  exposed  to  rheu- 
matic influences.     Perhaps  lead-poisoning  may  exist. 

It  begins  gradually  with  slight  pains  and  weakness  in  the 
shoulder  and  arm  muscles.  Atrophy  and  anaesthesia  follow,  and 
degeneration  reactions  are  present.  There  is  not  a  great  deal  of 
pain  (Fig.  74).  The  disease  is  usually  confined  to  one  side.  It 
lasts  several  months,  and  nearly  complete  recovery  finally  takes 
place.     .Relapses  may  occur. 

It  is  differentiated  from  progressive  muscular  atrophy  by  the 
pain,  anaesthesia,  and  electrical  reactions,  and  from  arthritic  atrophy 
by  the  absence  of  any  history  of  arthritis  and  the  presence  of  de- 
generation reactions  and  anaesthetic  areas. 

Paralyses  of  Single  Nerves — Paralysis  of  the  Pos- 
terior Thoracic  Nerve — Etiology. — This  rare  trouble  usually 
occurs  in  male  adults  and  is  due  to  injury  or  sudden  strains.  Its 
paralysis  may  be  part  of  a  progressive  muscular  atrophy.  The 
nerve  goes  to  the  serratus  magnus. 

Symptoms. — -When  paralyzed,  there  is  difficulty  in  raising  the 
arm  above  the  horizontal  position  and  the  movements  of  the  shoulder 
are  weakened.  When  the  arm  hangs  by  the  side  the  lower  angle  of 
the  scapula  is  drawn  a  little  nearer  the  vertebral  column  and  pro- 
trudes slightly.  When  the  arm  is  held  out  horizontally  the  inner 
edge  of  the  scapula  protrudes  and  is  drawn  toward  the  middle  line. 
When  the  raised  arm  is  brought  forward  there  is  a  deep  groove 
formed  between  the  inner  border  of  the  scapula  and  the  thoracic 
wall  (Fig.  76.) 

The  disease  often  runs  a  long  course  and  is  accompanied  by 
pain. 

-Paralysis  of  the  Circumflex  Nerve. — The  nerve  goes  to 
the  deltoid,  teres  minor,  third  head  of  the  triceps,  and  shoulder- 
joint.  It  gives  sensation  to  the  skin  of  the  shoulder.  It  is  very 
often  paralyzed.  The  commonest  causes  are  a  fall  or  injury,  dislo- 
cation, and  rheumatic  inflammation  of  the  joint.  The  arm  cannot 
be  elevated  or  rotated  outward.  There  are  atrophy,  anaesthesia, 
and  sometimes  pain. 

Paralysis  of  the  Suprascapular  Nerve. — The  nerve  goes 
to  the  spinati  muscles,  teres  minor,  and  shoulder-joint.  Disease  of 
this  nerve  alone  is  rare. 

The  supraspinatus  rotates  the  shoulder  in,  the  infraspinatus  and 
teres  minor  rotate  it  out.  When  paralyzed,  there  is  an  impairment 
of  rotation  and  some  impairment  of  elevation  of  the  shoulder. 

Paralysis  of  the  Musculo-Spiral  Nerve  (Wristdrop,  Lead 
Palsy,   Compression  Paralysis). — The  distribution  of  this  nerve  is 


142 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


given  in  the  table  and  cut.  Its  function  is  to  extend  and  supinate 
the  forearm,  to  extend  the  wrist  and  fingers,  and  to  adduct  and 
abduct  the  fingers  slightly.     It  extends  directly  only  the  last  or  un- 


Fig.  76.— Paralysis  of  Serratus  Magnus  op  Left  Side  (Leszynsky) 

gual  phalanges,  the  first  and  second  phalanges  being  extended  by 
the  ulnar  nerve. 

Etiology. — The  musculo-spiral,  owing  partly  to  its  course,  is  the 
most  frequently  affected  by  paralysis  of  all  the  arm  nerves.  Pres- 
sure on  the  nerve  during  sleep,  especially  when  the  patient  is  intoxi- 


NEUROSES    OF   THE    MOTOR    SPINAL   NERVES.  143 

cated,  crutch  pressure,  fractures,  wounds,  tumors,  lead  poisoning, 
arsenical,  alcoholic,  and  other  forms  of  multiple  neuritis  are  the 
causes  of  its  disordered  function. 

Symptoms. — The  symptoms  of  this  paralysis  are  "wristdrop," 
due  to  an  inability  to  extend  the  wrist  or  fingers.  The  first  and 
second  phalanges  can  be  extended  somewhat  by  the  interossei  and 
lumbricales,  but  the  last  phalanges  cannot  be  extended  at  all.  The 
first  finger  is  least  affected.  The  fingers  can  be  only  slightly  ab- 
ducted, supination  is  generally  lessened  or  lost ;  if  the  lesion  is  high 
up,  the  triceps  is  involved  and  the  power  of  extending  the  forearm 


Fig.  77. — Paralysis  op  Musci'lo-Spiral  Serve  and  Wristdrop. 

weakened.  There  may  be  atrophy  of  the  muscles  and  degeneration 
reaction.  A  swelling  over  the  tendons  of  the  wrist-joint  may  occur. 
Some  numbness  and  tingling  exist,  and  occasionally  there  is  anaes- 
thesia in  the  distribution  of  the  radial  nerve  on  the  hand.  The  dis- 
ease lasts  but  a  few  weeks  if  due  to  compression;  for  months  if  due 
to  neuritis,  lead  poisoning,  or  severe  injury  of  the  nerve.  Even- 
tually recovery  takes  place. 

When  the  disease  is  due  to  lead  poisoning  there  are  some  pecu- 
liarities in  its  course.  Thus  the  supinator  longus  usually  escapes; 
the  palsy  begins  gradually  and  usually  involves  both  arms;  it  may 
extend  to  the  upper  arm.  Partial  degeneration  reactions  are  pres- 
ent. There  is  rarely  any  amesthesia  and  but  little  pain.  Often 
there  is  a  lead  line  on  the  gum  and  a  history  of  constipation  and 
colic. 

In  alcoholic  and  other  forms  of  multiple  neuritis  there  are  pain 
and  paresthesia,  both  arms  are  involved,  and  the  flexors  and  other 
forearm  muscles  are  somewhat  implicated.  There  arc  marked 
sensory  disturbances.     The  legs  are  also  affect',]. 

In  compression  palsy  the  supinators  and  often  the  triceps  are 
involved. 

When  the  lesion  of  the  nerve  is  high  up,  as  in  crutch  paralysis, 


144 


DISEASES   OF   THE   NERVOUS    SYSTEM. 


there  is  but  little  anaesthesia,  and  that  is  found  on  the  anterior 
surface  of  the  forearm,  in  the  distribution  of  the  external  and  in- 
ternal cutaneous  nerves.  Lesion  of  the  nerve  lower  down  may  give 
rise  to  some  anaesthesia  along  the  radial  border  of  the  forearm  and 
back  of  hand ;  but  the  anaesthetic  area  varies  a  great  deal. 

The  diagnosis  of  the  paralysis  is  easily  made.  The  most  impor- 
tant point  is  to  find  out  the  cause.  The  different  characteristics  of 
lead  palsy,  neuritic  palsy,  and  compression  palsy  have  been  indi- 
cated in  the  description  of  the  symptoms.  One  must  be  sure  to 
exclude  also  progressive  muscular  atrophy. 

The  treatment  consists  of  mechanical  measures  such  as  elec- 
tricity, massage,  the  application  of  rubber  muscles,  and  in  bad  cases 
the  fixation  of  the  forearm  and  hand  in  hyperextension  by  means  of 
a  splint  and  plaster-of -Paris  bandage  (Gibney).  Internally  in  the 
early  stage  it  is  best  to  administer  iodide  of  potassium  and  sulphate 
of  magnesium  (in  lead  palsy),  the  salicylates  or  nitrate  of  silver  in 
neuritis;  later,  hypodermic  injections  of  strychnine  may  be  given. 
Static  sparks,  galvanism,  and  other  forms  of  electricity  unquestion- 
ably do  good  in  some  cases,  as  I  have  had  opportunity  to  prove. 

Paralysis  of  the  median  nerve  is  rare  as  an  isolated  trouble, 
and  is  almost  always  due  to  injury  or  neighboring  lesions.  Embo- 
lism of  the  axillary  artery  after  labor  has  produced  it. 


Fkj.  78.— Area  of  Anaesthesia,  in  Paralysis  op  the  Median  Nerve. 


When  paralysis  occurs  the  grip  is  weakened.  Flexion  and  ab- 
duction of  the  thumb  and  flexion  of  the  first  and  second  fingers  are 
impaired.  Atrophy  of  the  thenar  eminence  may  occur.  The  anaes- 
thetic area  varies,  but  is  well  shown  in  the  accompanying  cut 
(Pig.  78). 

Paralysis  of  the  Ulnar  Nerve — Etiology. — The  ulnar  nerve 
is  rather  commonly  affected   by  paralysis,   the   occurrence   rank- 


NEUROSES    OF   THE    MOTOR   SPIXAL    NERVES. 


145 


ing  next  in  frequency  to  nmsculo-spiral  palsy.  It  is  rarely  affected 
in  lead  poisoning,  but  is  usually  early  involved  in  progressive  mus- 
cular atrophy.  It  is  sometimes  attacked  by  a  primary  degenerative 
neuritis.     Injuries  are  the  common  cause. 

The  symptoms  are  shown  by  the  table  (p.  227).  The  hand  cannot 
be  closed  tightly,  the  little  and  ring  fingers  being  especially  weak. 
The  first  phalanges  are  drawn  back  and  the  second  and  third  pha- 
langes flexed;  when  the  interossei  and  lumbricales  atrophy,  the  re- 
sult is  the  "griffin  claw"  or  main  en  griffe.  The  fingers  cannot  be 
adducted  or  abducted  except  feebly. 


Fia.  70.—  Showix<;  Arf.a  of  Ax.bsthksia  in'  T'i.nak-Xerve  Palsy  (Bowlby). 


There  is  anaesthesia  over  the  area  of  distribution  of  the  ulnar 
(Fig.  79) ;  there  may  be  pain  and  tenderness. 

Symmetrical  Spontaneous  ITlnab  Neubitis. — A  form  of 
neuritis  of,  the  ulnar  nerve  sometimes  occurs  which  has  certain 
peculiar  characters.  It  develops  slowly  in  persons  with  a  neuro- 
pathic history,  and  without  known  exciting  cause.  There  are  first 
some  pain  and  paresthesia  in  the  region  of  the  ulnar  nerve  of  one 
hand  ;  this  is  followed  by  weakness  and  atrophy  of  the  inucles  sup- 
plied by  the  ulnar  nerve,  and  characteristic  deformity  appears. 
Anaesthesia  develops  coincidently.  The  other  hand  soon  becomes 
affected.  The  disease  is  very  chronic,  and  complete  recovery  is  rare. 
It  is  probably  a  form  of  degenerative  neuritis,  and  is  due  to  some 
infection. 

Migrating  neuritis  is  a  serious  but  rare  malady  which  deserves 
some  mention.  It  occurs  as  a  sequel  to  some  wound  of  or  operation 
upon  a  nerve.  The  local  neuritis  extends  usually  up  the  arm 
(ascending  neuritis).  It  is  accompanied  by  intense  pain,  anaes- 
thesia, paralysis,  and  atrophy.  The  disease  is  very  chronic  and 
intractable.  It  has  been  relieved  in  some  cases  by  resecting  the 
posterior  spinal  roots. 
10 


146 


DISEASES   OF   THE   NERVOUS   SYSTEM. 


Morvan's  Disease,  Analgesic  Paralysis  with  Whitlow. — 
(Neuritic  type  of  syringo-myelia.) 

This  is  a  very  rare  disease,  characterized  by  a  slowly  progressive 
paralysis  and  atrophy  of  the  hands  and  forearms,  with  analgesia 
and  painless  whitlows. 

It  occurs  usually  in  young  or  middle-aged  males.  Occupations, 
such  as  handling  fish,  which  involve  exposure  and  trauma,  predis- 
pose to  the  disease. 

The  symptoms  come  on  slowly,  with,  at  first,  severe  pains  in 
the  arms  and  hands.     The  muscles  of  these  parts  gradually  get 


Fig.  80.— Showing  the  Hands  in  a  Case  of  Paralysis  with  Whitlows  (Erb). 


weak  and  atrophy.  Anaesthesia  and  analgesia  are  present.  Usually 
there  is  loss  of  pain  and  temperature,  but  not  of  tactile  sense. 
Whitlows  appear  which  are  painless,  and  one  or  more  of  the  terminal 
phalanges  may  necrose.  There  is  usually  a  swelling  and  hard  oedema 
of  the  parts.  Both  upper  extremities  may  be  affected,  and  some- 
times the  feet  are  also  slightly  involved  (Fig.  80).  There  is  some- 
times spinal  curvature.  Hysteria  may  complicate  the  affection.  The 
course  of  the  disease  is  very  chronic,  but  there  may  be  long  periods 
in  which  the  symptoms  are  quiescent. 


NEUROSES   OF   THE    MOTOR    SPINAL   NERVES.  147 

Pathological  examinations  always  show  a  neuritis  of  the  parts 
involved  in  the  disease.  In  some  cases  a  syringo-myelia  has  been 
found.  There  is,  therefore,  a  Morvan's  disease  due  to  syringo- 
myelia and  neuritis,  and  another  type  due  to  a  neuritis  alone. 

The  prognosis,  so  far  as  cure  is  concerned,  is  bad,  but  the  disease 
may  remain  stationary  a  long  time  or  improve. 

The  diagnosis  is  based  on  the  combination  of  paralysis,  atrophy, 
loss  of  pain  and  temperature  but  not  of  tactile  sense,  and  whitlows. 
Leprosy  must  be  excluded. 

Strychnine  seems  to  have  stopped  the  progress  of  the  malady  in 
one  case.     The  treatment  in  general  is  only  symptomatic. 

Group  III.   The  Thoracic  or  Dorsal  Nerves. 

Anatomy  mid  Physiology. — The  dorsal  nerves  are  twelve  in 
number.  The  first  is  the  largest  and  belongs  functionally  to  the 
arm  nerves.  The  dorsal  nerves  carry  motor  and  sensory  fibres  to 
the  voluntary  muscles,  skin,  and  other  tissues  of  the  trunk  wall. 
They  also  carry  splanchnic  fibres  to  the  lungs  and  abominal  viscera. 
They  divide  into  anterior  and  posterior  branches.  The  anterior 
form  the  intercostal  nerves,  of  which  the  first  six  are  distributed  to 
the  wall  of  the  thorax  and  the  last  six  to  the  wall  of  the  abdomen. 
All  these  nerves  give  off  lateral  and  anterior  branches.  The  pos- 
terior branches  of  the  dorsal  nerves  are  small,  and  supply  the 
muscles  and  skin  of  the  back. 

Besides  the  above,  there  are  recurrent  branches  which  enter  the 
spinal  canal  and  supply  the  intraspinal  veins  and  membranes.  The 
first  six  dorsal  nerves  contain  fibres  which  enter  the  sympathetic 
and  supply  the  pleura  and  lungs.  Fibres  from  the  last  six  enter 
the  sympathetic  and  supply  the  pelvic  viscera.  The  intercostal 
nerves  in  their  course  lie  part  of  the  way  beneath  the  pleura;  they 
also  pass  along  in  close  company  with  the  intercostal  artery  and 
vein,  lying  just  above  these  in  the  groove  on  the  internal  surface 
and  inferior  border  of  the  ribs. 

The  upper  six  dorsal  nerves,  including  both  branches,  are  mainly 
inspiratory  in  function.     They  also  extend  and  rotate  the  dorsal  and 
cervical  vertebrae.     The  lower  dorsal  are  expiratory  nerves ;  they 
also  assist  in  compressing  the  abdominal  viscera,  and  in  flexin 
tending,  and  rotating  the  spine. 

Motor  Neuroses. — The  thoracic  motor  nerves  are  mainly  in- 
volved in  respiratory  cramps  and  paralyses;  sneezing,  coughing, 
laughing,  and  crying  are  symptoms  in  which  they  play  a  large 
part.  In  complete  respiratory  paralysis  also  these  nerves  arc  af- 
fected. But  there  are  few  motor  neuroses  that  an;  limited  to  the, 
thoracic  nerves.  The  neuroses  of  these  parts  are  mainly  sensory 
and  will  be  described  later. 


148 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


Group  IV.  The  Lumbar  Nerves. 

Anatomy  and  Physiology.— The  lumbar  nerves  are  five  in 
number.  The  posterior  branches  supply  the  erector  spinse,  inter- 
ossei,  multifidte  spinse  and  interspinales,  and  also  the  skin  of  the 
back.  The  anterior  branches  of  the  tipper  four  unite  to  form  the 
lumbar  plexus.  The  fifth  or  lumbo-sacral  nerve  sends  most  of  its 
fibres  to  the  sacral  plexus.  The  branches  of  the  lumbar  plexus  are : 
(1)  the  ilio-inguinal,  (2)  ilio-hypogastric  (from  first  lumbar),  (3) 
genito-crural,  and  (4)  external  cutaneous  (mainly  from  the  second), 
(5)  obturator  (from  third  and  fourth  lumbar),  (6)  the  anterior 
crural  (from  second,  third,  and  fourth — Fig.  81). 


8artorius;  anterior  >     Anterior 
thigh  muscles,      j  crural  nerve 

Adductors  and      InMnmfalr 
external  rotators  -     ,,    ™»or 
of  the  thigh.     )      ULl%e- 
Superior 
' '( gluteal  nerve. 

Pyriforniis 

obturator  int. 

gemelli. 

|  Smo  11  sciatic 
nerve. 


Glutei. 


Quad,  fem., 
Glut.  max. 


Muscular 

nerves. 


Adduct.  magn.  flexors  1   p_,„t      / 
or  km,  .extensor         <'[ef      ( 


of  loot,  calf  muscles, 


foot  muscles. 


J 


Bladder,     1 
perineum,  j  Pudic 
genitals,      f  nerve. 

sphincters.  J 


Fm.  81.— Diagram  showing  the   Origin  and  Distribution  of  the  Motor  and  Sensory 
Xerves  of  the  Lower  Limbs. 


The  first  four  branches  of  the  plexus  are  comparatively  short  and 
supply  sensation  to  the  abdominal  wall  and  external  genitals.  The 
last  two  are  longer  and  supply  the  hip  and  knee  joints,  the  muscles 
of  the  anterior,  inner,  and  outer  part  of  the  thigh,  the  skin  over 
this  region  and  the  inner  side  of  the  leg  and  dorsum  of  the  foot 
(Fig.  81). 

The  diseases  of  the  lumbar  nerves  and  plexus  so  far  as  they 
form  independent  disorders  are  mainly  the  neuralgias.  In  making 
a  diagnosis  of  lumbar-nerve  disease,  one  should  remember  that  of 


NECROSES    OF   THE    MOTOR   SPINAL   NERVES.  149 

the  six  branches  of  the  plexus  the  upper  four  are  mainly  sensory, 
the  lower  two  mixed  nerves. 

Paralyses  and  spasmodic  troubles  of  the  lumbar  nerves 
are  not  rare,  but  are  usually  symptomatic  of  some  extrinsic  and 
often  serious  disease. 

Etiology. — Hence  it  is  well  to  catalogue  here  those  affections 
which  may  produce  lumbar  palsies  or  spasms.  They  are  pelvic 
tumors  or  injuries,  impacted  faeces,  caries  of  the  spine,  psoas  ab- 
scess, obturator  hernia,  hip  disease,  and  pressure  of  the  foetal  head. 

Symptoms. — When  the  upper  two  lumbar  nerves  are  involved, 
only  sensory  symptoms  in  the  distribution  of  their  branches  occur 
(Fig.  81).  If  the  next  two  are  also  involved,  there  may  be  trouble 
in  extending  the  leg  and  flexing  the  hip  on  the  trunk.  The  patient 
cannot  raise  himself  to  a  sitting  posture.  If  there  are  irritation  and 
spasm,  the  thigh  is  drawn  up  and  adducted. 

In  paralysis  of  tin;  obturator  nerve  there  are  loss  of  power  to  adduct 
the  thigh  and  cross  the  leg  and  weakness  of  outward  rotation  of  the 
thigh.     Anaesthesia  over  the  inner  side  of  the  thigh  may  be  present. 

In  "paralysis  of  the  anterior  crural  nerve  there  are  weakness  of  the 
muscles  of  the  anterior  surface  of  the  thigh,  loss  of  power  of  extend- 
ing the  leg,  and  anaesthesia  or  pain  over  the  crural  area. 

Paralysis  of  the  posterior  branches  of  the  lumbar  nerves  causes 
weakness  or  paralysis  of  the  erectors  of  the  spine.  The  lumbar 
curve  is  very  greatly  exaggerated,  the  shoulders  being  thrown  far 
back  and  the  belly  protruding.  This  condition  occurs  in  progressive 
muscular  atrophy,  particularly  in  the  pseudo-hypertrophic  form. 

Group  V.  The  Sacral  Nerves. 

Anatomy  mat  /'/, ysiology. — The  sacral  nerves  are  five  in  number. 
The  first  four  divide  into  anterior  and  posterior  branches.  The  fifth 
has  no  anterior  branch.  The  posterior  branches  escape  through  the 
posterior  sacral  foramina  and  supply  the  multifidus  spinae  and  the 
skin  over  the  sacrum  and  coccyx. 

The  first  three  anterior  branches,  with  the  lumbo-sacral  nerve 
and  a  branch  from  the  fourth  sacral,  unite  to  form  the  sacral  plexus. 
This  lies  upon  the  pyxiformis  muscle  in  the  pelvis,  and  escapes  at 
the  lower  part  of  the  sacro-sciatic  foramen.  The  great  mass  of  the 
fibres  go  to  make  up  the  sciatic  nerve. 

The  roots  of  origin  of  the  sacral  and  ooccygea]  nerves  form  the 
cauda  equina. 

The  branches  of  the  sacral  plexus  are  the  superior  gluteal,  mus- 
cular, small  sciatic,  inferior  gluteal,  pudic,  greal  sciatic  perforat- 
ing, cutaneous,  and  articular.  These  are  distributed  to  the  muscles, 
skin,  and  joints  of  the  buttocks,  thighs,  legs,  and  feet.  Their  dis- 
tribution is  shown  in  Fig.  81. 


150  DISEASES   OF  THE   NERVOUS   SYSTEM. 

The  sacral  nerves  are  the  main  agents  in  station  and  locomotion. 
They  control  the  legs  entirely,  also  the  posterior  muscles  of  the  thigh 
and  buttocks ;  they  give  sensation  to  these  parts.  They  carry  also 
fibres  that  regulate  the  sexual  function,  bladder,  and  rectum.  From 
the  sacral  portion  of  the  cord  there  is  an  outflow  of  nerves  to  the 
sympathetic,  thence  to  the  pelvic  organs. 

The  diseases  of  the  sacral  nerves  may  be  classified  in  a  similar 
way  to  those  of  the  brachial  plexus. 

Spasmodic  Disorders  of  the  Sacral  Nerves. — Tremor, 
rigidity,  clonic  and  tonic  spasms,  myoclonus,  athetoid  movements, 
all  affect  the  lower  extremities,  but  they  are  almost  invariably  part 
of  some  general  or  central  disorder,  such  as  chorea,  paralysis  agi- 
tans,  hysteria,  etc.  Under  the  head  of  occupation  neuroses  there 
occur  certain  rare  spasmodic  troubles  special  to  the  legs.  Saltatory 
spasm  involves  the  legs  alone.  These  disorders  are,  however,  gen- 
eral neuroses. 

Peripheral  Leg  Palsies. — Paralyses  of  the  lower  limbs  from 
disease  of  the  nerves  may  be  either  combined  or  single,  just  as  is  the 
case  with  arm  palsies. 

A  combined  sacral  palsy  is  one  in  which  all  or  nearly  all  of  the 
branches  of  the  sacral  plexus  are  involved. 

Etiology. — Such  palsies  are  due  to  much  the  same  causes  as 
those  affecting  the  lumbar  nerves,  viz.,  injury,  dislocation,  hip 
disease,  tumors,  and  neuritis.  Hysteria  may  cause  a  functional 
sacral  palsy. 

Symptoms. — The  symptoms  are  indicated  by  a  study  of  the  dis- 
tribution of  the  nerves,  varying,  however,  in  degree.  The  foot 
cannot  be  moved ;  the  leg  can  be  slightly  extended  by  the  anterior 
crural,  but  not  flexed;  the  thigh  cannot  be  drawn  back  freely  or 
rotated  perfectly.  There  is  anaesthesia  over  the  distribution  of 
the  sacral  nerves ;  pain  may  be  present ;  wasting  and  vasomotor  and 
secretory  disturbances  occur  unless  the  paralysis  is  functional. 

The  course  depends  on  the  severity  of  the  lesion.  If  the  nerve 
is  totally  cut  or  torn  across,  it  may  require  one  or  two  years  for 
perfect  recovery,  which,  however,  occurs  if  the  severed  ends  are 
properly  approximated. 

The  diagnosis  of  a  sacral  palsy  is  based  on  the  history  and  on 
the  distribution  of  the  anaesthesia  and  of  the  muscular  paralysis. 
The  sacral  nerves  do  everything  for  the  lower  limb  except  extend 
the  leg,  flex  and  adduct  the  thigh,  and  to  some  extent  rotate  it. 
They  supply  sensation  equally  extensively  (see  Pig.  81). 

The  distinction  from  spinal-cord  disease  is  chiefly  based  on  the 
unilateral  symptoms,  the  absence  of  disorder  of  the  sphincters,  and 


NEUROSES   OF   THE   MOTOR   SPIRAL   NERVES.  151 

the  combination  of  paralysis,  wasting,  and  sensory  troubles,  in  the 
course  of  the  sacral  nerves. 

Single-Nerve  Sacral  Palsies. — The  symptoms  of  paralysis 
of  single  nerves  are  indicated  by  their  function.  The  nerves  rarely 
affected  are  the  superior  gluteal,  muscular,  and  small  sciatic.  The 
nerve  oftenest  affected  is  the  great  sciatic,  and  especially  its  anterior 
tibial  branch.  In  the  latter  case  a  condition  called  "  dropfoot''  is 
produced. 

In  the  pathology  and  treatment  of  sacral  palsies  there  is  uothing 
especial  that  can  be  said. 


CHAPTER   X. 

SENSORY    NEUROSES    OF    THE    CEREBRO  -  SPINAL 

NERVES. 

As  the  most  common  disorders  of  the  sensory  nerves  are  neuralgias 
and  paresthesias,  1  shall  introduce  the  subject  with  a  general  de- 
scription of  these  symptoms. 

PARESTHESIA. 
Local  Paresthesia,  Acro-pak.esthesia,   Waking  Numbness. 

The  condition  known  as  paresthesia  is  one  which  should  be  more 
familiar  to  physicians,  and  be  more  commonly  recognized  and  under- 
stood. Parcesthesia  is  the  name  given  to  a  number  of  subjective 
sensations,  such  as  prickling,  numbness,  creeping  sensations,  tick- 
ling, and  burning.  It  includes,  in  fact,  nearly  all  the  subjective 
sensations  of  the  skin,  except  those  of  pain.  It  is  a  condition 
which  is,  therefore,  extremely  common,  and  in  its  mildest  and 
most  trivial  character  is  much  more  often  experienced  than  pain. 
When  these  sensations  fix  themselves  in  a  certain  locality,  follow- 
ing perhaps  the  tract  of  the  nerve,  or  fastening  themselves  upon 
the  hand  or  foot,  they  take  on  a  certain  clinical  picture,  and  de- 
serve to  have  the  name  of  a  disease,  to  just  the  same  extent  that 
a  neuralgia  does.  Paresthesia,  in  almost  all  cases,  implies  simply 
a  lower  grade  of  irritation  of  the  nerve  fibres  than  occurs  in  neu- 
ralgia, and  is  a  kind  of  ghostly  simulacrum  of  that  disease.  It 
very  often  precedes  or  accompanies  attacks  of  pain.  There  is  some- 
times a  tingling  of  the  teeth  or  burning  in  the  face  which  has  a 
shadowy  likeness  to  a  toothache  or  trigeminal  neuralgia.  In  the 
same  way,  one  finds  paresthesias  affecting  the  head,  causing  sensa- 
tions of  pressure  and  constriction,  of  burning,  and  general  undefin- 
able  discomfort,  which  are  entirely  comparable  to  headaches. 

In  conditions  of  neurasthenia,  paresthesias  of  the  head  are  more 
common  even  than  the  headaches.  Paresthesia  sometimes  follows 
the  course  of  a  nerve,  as  when  one  feels  numbness  of  the  hand  if 
the  ulnar  is  pressed  upon  at  the  elbow,  or  numbness  in  the  foot 
when  the  sciatic  is  pressed  upon,  as  when  the  legs  are  crossed. 

There  is  also  paresthesia  affecting  one  of  the  intercostal  nerves 
ox  one  of  the  crural  nerves.     On  the  other  hand,  paresthesia  may 


SEXSOKT    XEUROSES   OF   THE    CEREBRO-SPIXAL   MTBBVES.       153 

affect  all  four  extremities,  so  that  they  feel  entirely  benumbed  or 
prickling.  There  is,  I  repeat,  a  very  close  analogy  between  these 
groups  of  paresthesias  and  neuralgias. 

Etiology. — Paresthesia,  whether  local  or  diffuse,  occurs  rather 
more  often  in  women  than  in  men,  and  rather  more  often  in  the 
mature  and  middle-aged  than  in  young  people.  It  is  most  frequent 
in  women  of  middle  age,  especially  in  those  who  are  accustomed  to 
hard  work  with  the  hands  in  washing  and  the  exposure  incidental 
to  this.  It  also  occurs  in  those  who  are  obliged  to  walk  a  great  deal 
and  to  be  upon  their  feet,  and  it  especially  affects  tailors,  seam- 
stresses, bookbinders,  and  those  who  have  to  use  their  hands  con- 
stantly in  some  skilled  mechanical  work.  It  sometimes  occurs  in 
old  age,  being  accompanied  by  evidence  of  gout  or  glycosuria  in 
some  cases.  It  is  associated  with  rheumatism  (twelve  per  cent 
of  cases)  and  with  alcoholism  (eight  per  cent  of  cases).  It  follows 
infections  like  typhoid  fever  and  the  grippe,  and  means  in  these,  as 
in  many  other  cases,  a  low  grade  of  neuritis.  As  a  rule,  however, 
paresthesia  is  a  neurosis  in  which  exposure,  rheumatism,  alcohol, 
arterial  sclerosis,  and  litheinia  are  the  causes. 

Paresthesia  affects  single  cerebro-spinal  nerves  just  as  neuralgia 
does,  or  it  may  be  more  generally  distributed.  In  the  latter  case 
it  affects  most  the  feet  and  hands,  and  it  is  called  acro-parcesthesia. 

We  meet  then  with : 

1.  Cephalic  paresthesias,  comparable  to  diffuse  headaches. 

2.  Local  paresthesias,  compararable  to  local  neuralgias. 

3.  Acro-paresthesia,  involving  the  feet  or  hands  or  both  diffusely. 
The  cephalic  paresthesias  are  usually  symptoms  of  neurasthenic 

or  lithemic  states  and  will  not  be  considered  here.  Among  eighty- 
five  cases  of  local  and  acro-paresthesie,  not  symptomatic  of  other 
and  organic  nerve  disease,  I  found  that  there  were  of  the  local  forms 
thirty-five  cases,  of  acro-paresthesia  fifty  cases.  The  local  paresthe- 
sias affected  the  arms  in  eighteen  cases,  next  the  thigh  and  leg  nerves 
in  twenty  cases,  and,  last,  the  trigeminal  nerve  in  three  cases.* 

*  The  following  analysis  of  eighty -live  cases  of  paresthesia  occurring  in 
my  practice  shows  something  of  the  cause  and  local  development  of  the 
malady.  The  most  frequent  causes  I  find  to  be  those  concerned  with  occupa- 
tion. Parasthesia,  in  its  general  manifestations,  may  lie  considered  almost 
an  occupation  neurosis.     The  list  of  cases  may  lie  put  down  as  follows  : 


Occupation 15 

Rheumatism 10 

Alcoholism 6 

Infection 6 

Senility 6 


Reflex  irritation 2 

Hysteria 3 

Climacteric  change 2 

Various   causes,  BUch   as   neuras- 
thenic state,  puerperium,  etc..  13 


Among  85  cases  there  were  36  males  and  41)  females  ; 


154  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Symptoms. — The  patients  have  feelings  of  numbness,  prickling, 
coldness,  heaviness,  usually  in  both  hands,  extending  a  little  way 
up  the  forearm  and  often  also  in  the  feet.  The  sensations  are, 
as  a  rule,  diffuse,  but  may  follow  the  distribution  of  a  nerve,  espe- 
cially the  ulnar.  In  other  cases  the  numbness  is  sharply  limited  to 
the  finger  tips  or  the  second  and  third  phalanges.  There  is  no  actual 
pain  or  tenderness,  nor  is  there  any  anaesthesia,  cutaneous  or  mus- 
cular. Instead  of  or  with  the  numbness  there  may  be  burning  sen- 
sations, especially  felt  in  the  palms  or  soles.  There  is  often  a  slight 
degree  of  paralysis,  but  rarely  any  decided  vasomotor  or  trophic 
changes.  The  symptoms  exacerbate,  being  worse  at  certain  periods 
of  the  day,  usually  in  the  morning.  They  may  increase  at  night 
and  prevent  sleep.  The  arms  are  oftener  affected  than  the  lower 
extremities ;  and  the  symptoms  never  except  in  hysteria  take  a  hemi- 
plegic  form,  though  one  arm  may  be  alone  involved.  The  scalp 
and  ears  may  be  involved,  though  always  in  a  minor  degree,  the 
patient  complaining  of  sensations  of  heat,  prickling,  flushing,  and 
vertex  pressure.  In  the  local  forms,  there  is  numbness  along  the 
ulnar  nerve  or  in  one  arm  or  along  some  branch  of  the  lumbar 
nerves  (meralgia).  The  symptoms  cause  a  condition  of  mental 
unrest  and  nervousness  which  add  to  the  sufferings  materially. 
Evidences  of  overwork,  of  dyspepsia  and  constipation,  of  anaemia, 
or  of  muscular  rheumatism  will  generally  be  found.  The  urine  is 
usually  rather  light  in  color  and  specific  gravity  (1.010  to  1.018), 
slightly  cloudy,  with  excess  of  phosphates  and  occasional  excessive 
discharges  of  urates.  Under  the  head  of  parsesthesic  neurosis,  the 
affection  known  as  waking  numbness  or  night  palsy  may  be  described. 

This  is  a  disorder  characterized  by  a  temporary  paralysis  of  an 
extremity,  with  numbness,  noticed  on  first  waking  or  after  lying 
down  for  a  time. 

Males.       Females        Total. 

Hands  and  feet,  or  both,  affected 

Hands  alone 

Feet  and  legs 

General  sensations , 

Local , 14 


6 

11 

17 

6 

12 

18 

10 

10 

20 

4 

4 

14 

12 

26 

The  special  nerves  affected  were  : 

Trigeminal 4 

Brachial 5 

Ulnar 7 

Radial 1 

Crural 4 

Peroneal  1 


36  49  85 

Sacral 1 

Sciatic  . . . .  , 1 

Plantar 11 

35 


SENSORY    NEUROSES   OF   THE    CEREBRO-SPINAL    NERVES.       155 

It  is  a  rare  disease  and  little  is  known  of  its  cause.  It  occurs  in 
adults  and  usually  in  the  neuropathic.  Sometimes  evidence  of 
weak  heart  or  poor  innervation  of  the  vessels  is  present. 

The  symptoms  are  much  like  those  caused  by  temporary  com- 
pression of  a  nerve  when  the  leg  or  arm  goes  to  sleep.  The  paralysis 
is  temporary  and  there  is  no  anaesthesia.  It  is  often  a  very  obsti- 
nate condition  but  leads  to  no  serious  result. 

Pathology. — The  pathology  of  paresthesia  is  based  upon  the 
similarity  of  the  symptoms  to  those  in  mild  or  incipient  cases  of 
neuritis  and  upon  the  effects  of  drugs  in  relieving  symptoms.  It 
is  believed  that  the  peripheral  nerves  are  being  irritated  by  some 
poison  circulating  in  the  blood.  Co-operating  with  this  are  nerves 
naturally  over-irritable,  or  made  so  by  anaemia,  hyperemia,  or  ex- 
posure to  cold.  In  some  cases  there  is  undoubtedly  a  low  grade 
of  neuritis,  and  in  other  cases  there  is  a  congestion  or  slight  degree 
of  degeneration  of  the  nerve. 

Diagnosis. — The  condition  is  to  be  distinguished  from  hysteria, 
neurasthenia,  multiple  neuritis,  occupation  neuroses,  and  central 
organic  diseases  of  cord  or  brain.  In  hysteria  the  symptoms  are 
less  diffuse,  regular,  and  bilateral,  while  some  anaesthesia  is  rarely 
absent.  Paresthesias  are  very  common  in  neurasthenia,  and  in  some 
cases  here  they  are  due,  no  doubt,  to  peripheral  irritation.  In 
neurasthenia,  the  paresthesias  are,  however,  generally  in  one  ex- 
tremity, less  diffuse,  and  as  a  rule  more  temporary.  There  is  no 
motor  weakness,  and  the  head  and  spine  are  usually  complained  of 
more  than  the  arms  or  legs.  Waking  numbness  and  night  palsy  are 
intermittent  disorders,  disappearing  within  a  short  time  after  wak- 
ing or  rising  from  a  recumbent  posture.  The  numbness  that  is  felt 
with  digiti  mortui  and  Raynaud's  disease  is  accompanied  by  spasm 
of  the  blood-vessels  and  whitening  of  the  fingers.  In  multiple  neu- 
ritis there  is  usually  some  distinct  anaesthesia,  pain,  or  tenderness, 
and  also  motor  weakness. 

Prognosis  and  Course. — The  disease,  if  not  treated,  runs  a  course 
of  several  months,  with  some  intermissions  and  relapses.  It  may 
disappear,  to  return  the  next  year.  It  never  progresses  to  any 
serious  condition,  and  is  in  almost  all  cases  eventually  cured. 

Treatment. — The  patient  should  receive  alkalies,  with  bromides, 
pepsin,  iron,  and  strychnine.  The  faradic  current,  massage,  and 
stimulating  liniments  are  useful.  Rest  and  removal  from  exciting 
causes,  such  as  exposure  and  special  work,  are  also  indicated. 


156  DISEASES    OF   THE    NERVOUS   SYSTEM. 


NEURALGIA. 

Neuralgia  is  a  condition  characterized  by  pain  in  the  course  of  a 
nerve  or  of  nerves. 

Forms. — Neuralgias  may  be  idiopathic,  i.e.,  developed  sponta- 
neously; or  symptomatic,  i.e.,  due  to  some  known  toxic  influence, 
reflex  irritant,  or  organic  disease  acting  on  the  nerve.  Thus  a 
central  disease  of  the  nervous  system  or  a  tumor  pressing  on  a  nerve 
may  cause  a  symptomatic  neuralgia.  When  there  is  organic  disease 
of  the  nerve  itself,  such  as  neuritis,  the  disease  cannot  be,  strictly 
speaking,  called  neuralgia,  but  it  is  often  impossible  to  draw  the 
lines  absolutely. 

Neuralgias  are  divided,  in  accordance  with  their  cause,  into  the 
epileptiform,  hysterical,  reflex,  traumatic,  gouty,  etc. 

Neuralgias  are  also  divided,  in  accordance  with  their  anatomical 
location,  into  trigeminal,  cervico-occipital,  brachial,  intercostal, 
lumbar,  crural,  sciatic,  and  visceral. 

Migraine  and  headache  are  not  classed  among  neralgias. 

Neuralgias  of  all  kinds  make  up  about  ten  per  cent  of  the 
nervous  disorders  for  which  the  neurologist  is  consulted.  The  most 
frequent  form  is  the  trigeminal ;  next  in  order  come  the  sciatic,  in- 
tercostal, cervico-occipital,  lumbo-abdominal,  brachial,  and  visceral 
neuralgias. 

Etiology. — Neuralgia  never  affects  young  children,  and,  leaving 
out  migraine  and  headache,  it  is  rarely  met  with  before  the  fifteenth 
year.  From  that  time  until  twenty -five  the  frequency  very  rapidly 
increases.  About  one-fourth  of  all  cases  occur  between  the  ages  of 
fifteen  and  twenty -five;  the  relative  number  then  slowly  decreases 
to  the  forty-fifth  year,  when  there  is  a  rapid  fall.  Neuralgia  is  very 
rare  in  old  age. 

Women  are  more  affected  than  men,  in  the  proportion  of  five  to 
three  (analysis  of  887  cases).  In  New  York  most  cases  occur  in 
winter,  next  in  the  autumn.  More  cases  occur  in  temperate  climates 
and  in  wet  and  cold  regions. 

Hereditary  influence,  neurotic  constitution,  anaemia  and  debility, 
gouty  and  rheumatic  diatheses,  all  predispose  somewhat  to  the  dis- 
ease. The  exciting  causes  can  be  included  under  the  head  of  toxic 
agents,  infections,  exposure,  overexertion,  emotional  shock,  injuries, 
and  neuritis  of  low  degree. 

Local  irritation  of  nerves  may  excite  neuralgia,  direct  or  reflex 
in  kind.  Some  help  in  recognizing  the  reflex  origin  of  neuralgias 
and  other  pains  may  be  gained  from  the  accompanying  diagrams. 


SENSORY    NEUROSES    OF    THE    CEREBRO-SPINAL    NERVES.       15? 

Symptoms. — These  will  be  described  in  detail  in  the  chapters  on 
the  special  forms. 

The  dominant  symptom  is,  of  course,  pain.  This  pain  is  sharp, 
darting,  boring,  stabbing,  or  burning  in  character.     It  comes  on  in 


Ot+rf. 


Fig.   82. —Diagrams   showing  the    Distribution   of  the    Cerebro-Spinal   Strands  op 
Nerves  and  the  Location  of  Transferred  Pains  and  Neuralgia. 


Area  I... 
Area  II.. 
Area  III 


Area  IV. 


Strands  of  Cerebro-Spinal  Nerves. 


Trigeminus,  facial,  etc. 
Upper  four  cervical. 
Lower  four  cervical  and  first  dor- 
sal. 
Upper  six  dorsal 


Area  V Lower    ix  dorsal  except  last. 

Area  VI  Twelfth  dorsal,  four  lumbar. 

Area  VII Fifth  lumbar  and  five  sacral. 


Distribution. 


Face  and  Lis  orifices,  anterior  scalp. 
Occipital  region,  neck. 

Upper  exii'eiM 

Thoracic  wall. 

Abdominal  wall.  Upper  lumbar,  upper 

lateral  thigh  surface. 

Lumbar   region,  upper  gluteal,  ante- 
rior and  inner  thigh  and  knee. 

Lower  gluteal,  posterior  thigh,  leg. 


paroxysms  of  great  intensity.  In  the  intervals  there  may  be  no 
pain  or  it  may  be  simply  a  dull  ache.  The  pain  runs  along  the 
course  of  certain  nerves,  though  it  is  not  confined  necessarily  to 
them,  but  may  be  somewhat  diffuse.  Pain  is  increased  or  brought 
on  by  cold  or  heat,  or  pressure  un  the  affected  part. 


158  DISEASES   OF    THE   NERVOUS   SYSTEM. 

The  skin  and  nerves  are  sometimes  tender  or  even  exquisitely 
sensitive.  Firm  pressure,  however,  is  usually  not  painful.  In 
about  half  the  cases  of  long  standing,  tender  points  may  be  found 
which  correspond  to  the  exit  of  nerves  from  a  bony  canal  or  the 
substance  of  a  muscles  or  fascia.  In  rare  cases  there  is  tenderness 
over  the  spine  corresponding  to  the  point  where  the  affected  nerves 
arise.  Besides  feelings  of  pain,  there  is  often  a  sense  of  numb- 
ness, cold,  tingling,  or  heaviness  of  the  limb.  Vasomotor,  secre- 
tory, and  trophic  disturbances  may  occur ;  but  when  these  are  pro- 
nounced one  must  suspect  neuritis  or  an  organic  central  disease. 
Muscular  spasm  is  sometimes  present ;  more  rarely  there  is  some 
muscular  weakness.  The  paroxysms  of  pain  may  intermit  regu- 
larly; sometimes  they  come  on  every  day  at  the  same  hour.  They 
are  apt  to  be  worse  at  night.  The  attacks  of  the  disease  often  run 
a  course  of  several  weeks  or  months,  and  in  some  forms  they  last 
for  years. 

The  painful  sensations  of  neuralgia  usually  originate  in  the 
peripheral  sensory  neuron.  In  some  cases  the  posterior  spinal 
ganglion  is  chiefly  at  fault  (Anstie) ;  in  others  the  irritation  affects 
the  entire  sensory  nerve.  The  central  sensory  neurons  that  carry 
impulses  to  the  brain  are  rarely  the  cause  of  neuralgia,  and  local 
diseases  of  the  cord  and  brain  do  not,  as  a  rule,  cause  pain  by 
irritating  these  sensory  pathways.  Still  there  may  be  neu- 
ralgic pain  from  this  cause ;  and  "  central  nervous  pains "  have 
been  observed  in  brain  tumors  and  after  brain  hemorrhage  or 
softening. 

Pathology. — Many  cases  that  used  to  be  called  neuralgia  are 
now  known  to  be  forms  of  neuritis,  e.g.,  sciatica  and  brachial  neu- 
ralgia. Other  forms  are  sometimes  due  to  impaired  nutrition  of  the 
neuron  from  an  obliterating  arteritis  (tic  douloureux)  ;  still  others 
are  due  to  the  irritation  of  nerves  from  the  diathetic  poison  of  gout, 
rheumatism,  and  diabetes,  or  to  extrinsic  poisons,  such  as  alcohol, 
lead,  and  arsenic.  In  these  cases  the  sensory  nerves  of  the  nerve 
sheaths  (nervi  nervorum)  are  affected.  There  remain  many  cases 
in  which  the  trouble  shifts  from  one  locality  to  another,  or  in  which 
no  special  local  or  general  irritation  can  be  discovered.  In  these 
cases  we  assume  that  the  pathogenic  focus  is  in  the  spinal  or  cere- 
bral sensory  neurons. 

There  are  some  forms  of  neuralgia  which  may  be  called  "rem- 
iniscent" or  "hallucinatory."  The  patient,  who  is  an  impres- 
sionable and  sensitive  person,  has  had  a  genuine  cause  for  neuralgic 
pains;  but  this,  after  lasting  some  time,  has  ceased,  while  the  pain- 
ful impressions  continue  to  remain  in  the  cerebral  cortex.     The 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPIXAL   NERVES.       159 

neuralgia  is  a  morbid  habit  of  feeling  pain.  Such  neuralgias  are 
promoted  often  by  the  use  of  morphine. 

Diagnosis. — This  is  based  on  the  fact  that  neuralgic  pains  are 
shifting,  paroxysmal,  follow  the  course  of  nerves,  are  accompanied 
often  by  tender  points  and  not  accompanied  by  signs  of  organic 
nerve  disease,  such  as  paralysis,  anaesthesia,  and  tenderness  over 
the  nerve  trunks.  Thermic  sensations  of  burning  or  cold  are  rarely 
neuralgic,  but  are  due  to  neuritis. 

Prognosis  is  good,  except  for  the  reminiscent  neuralgias,  the 
neuralgias  of  hysterical  and  neurasthenic  persons,  who  are  thoroughly 
anaemic,  debilitated,  aged,  and  broken  down  morally  and  physi- 
cally. The  neuralgias  of  the  degenerative  period  of  life  are  also 
very  obstinate. 

The  treatment  will  be  discussed  under  special  heads. 


NEUROSES  OF  THE   NERVES  OF  SPECIAL  SENSE. 

The    Olfactory  Nerve. 

Anatomy. — The  olfactory  nerves  consist  of  a  number  of  peri- 
pheral fibres  that  arise  from  the  olfactory  bulb,  pass  through  the 
cribriform  plate  of  the  ethmoid  bone,  and  are  distributed  to  the 
mucous  membrane    of    the    superior    and  middle  turbinated  bones 


Fig.  83.— Showing  the  Olfactory  Nerve,  also  a  Portion  of  the  Trigeminus. 

and  the  upper  part  of  the  nasal  septum.  The  olfactory  bulb 
is  with  its  associated  parts  really  a  subdivision  of  the  brain  (rhi- 
nencephalon)  and  not  a  true  nerve.  For  many  reasons  the  anat- 
omy of  the  rhinencephalon  has  a  peculiar  interest.  It  is  developed 
from  a  secondary  division  of  the  first  cerebral  vesicle.     It  includes 


160 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


in  man,  from  before  backward,  the  bulb  and  peripheral  nerves,  the 
olfactory  tracts,  and  their  lateral  roots  with  the  gray  root  or  tri- 
gonum  between  them,  the  hippocampal  convolution  and  cornua 
ammonis,  part  of  the  convolution  of  the  corpus  callosum,  the 
nerves  of  Lancisi,  and  the  anterior  commissure.  Recent  studies  of  the 
anatomy  of  the  olfactory  bulb  and  its  nerves  show  that  this  ap- 
paratus is  very  analogous  to  that  of  the  retina.  Beginning  with 
the  nerve  cells  of  the  nasal  mucous  membrane,  it  is  found  that  these 
are  bipolar,  and  are  analogous  to  the  cells  of  the  posterior  spinal 


Ependymal 

epithelium. 


Layer  of 
mitral  cells. 


Layer  of 
olfactory 
fibrillae. 


Nasal 
J  epithelium. 

Fig.  84.—  Principal  Constituent  Elements  of  the  Olfactory  Nerve  of  a  Mammal 

(Van  Gehuchten). 


ganglia;  they  send  peripheral  processes  between  the  epithelial  cells,, 
and  these  processes  receive  the  olfactory  stimulus ;  the  other  and  cen- 
tral processes  pass  up  through  the  ethmoid  bone  to  the  bulb.  These- 
form  the  so-called  nerves  of  smell.  They  eud  in  fine  expansions 
which  unite  with  similar  terminal  expansions  from  a  deeper  layer  of 
cells.  The  tangle  of  fibres  forms  what  are  known  as  the  glomerular 
bodies.  Next  is  a  layer  of  peculiar  cells,  called  from  their  shape  mi- 
tral. They  have  neuraxons  which  become  part  of  the  olfactory 
tract.  Deeper  still  is  a  layer  of  granular  and  central  fibres,  the- 
former  being  peculiar  in  having  no  axis  cylinders.     These  cells  re- 


SENSORY    NEUROSES    OF    THE    CEREBRO-SPINAL    NERVES.       161 

semble  the  spongioblast  cells  of  the  retina  and  are  associative  in 
function.  The  central  olfactory  fibres,  which  are  now  neurons  of 
the  third  order — that  is  to  say,  they  are  the  third  from  the  peri- 
pheral olfactory  cell — pass  to  the  hippocampus,  cornu  ammonis,  and 
convolution  of  the  corpus  callosum.  Through  cells  in  these  areas 
they  are  put  in  connection  with  the  optic  thalamus  and  with 
the  motor  tracts.     The  olfactory  nerves  do  not  decussate. 

The  sense  of  smell  is  rudimentary  in  man,  yet  it  is  still  the 
sense  by  which  we  can  appreciate  the  most  attenuated  matter;  for 
the  trillionth  of  a  grain  of  mercaptan  is  able  to  awaken  a  sensation 
in  the  mind,  but  has  weight  and  dimensions  so  infinitely  minute  as  to 
be  quite  beyond  the  power  of  the  imagination  to  grasp.  According 
to  Valentin,  we  can  perceive  TTTr£- 5-^  of  a  grain  of  oil  of  roses. 
According  to  Fischer  and  Penzoldt,  one  can  perceive  irnr-7rL()  tf  of 
a  grain  of  mercaptan.  I  have  found  that  one  can  perceive  the  odor 
from  1  cm.  of  a  solution  of  oil  of  cloves,  1  to  100,000.  Matter  to 
be  perceived  as  odor  must  be  in  a  gaseous  form.  Odorous  sensa- 
tions co-operating  with  taste  sensations  form  "flavor."  Variety  in 
odorous  sensations  depends  probably  upon  the  rapidity  of  molecular 
vibrations  as  in  the  case  of  light;  and  substances  having  similar  re- 
lations in  vibration  have  similarity  in  odor  (Haycraft).  Males  have 
a  more  delicate  sense  of  smell  than  females  (Nieolls  and  Bailey). 
The  keenness  of  the  olfactory  sense  is  lessened  in  the  insane  and 
criminal  classes. 

Anosmia. — The  olfactory  nerve  is  affected  clinically  by  loss  of 
function,  or  anosmia;  increased  sensitiveness  of  function,  or  hy- 
perosmia,  and  perversions  of  function,  or  parosmia. 

Anosmia  is  far  the  most  common  disorder  of  olfaction. 

Etiology. — Its  usual  cause  is  disease  of  the  mucous  membrane  of 
the  nose.  Injuries,  inflammations,  and  tumors  affecting  any  part 
of  the  course  of  the  nerve,  its  bulb,  or  central  fibres,  may  also  cause 
it.  Unilateral  cortical  lesions  in  the  uncinate  gyrus  may  lead  to 
partial  loss  of  smell.  It  will  be  not  entire,  because  each  nerve  re- 
ceives fibres  from  both  hemispheres.  Paralysis  of  the  fifth  <>r  sev- 
enth nerve  may  indirectly  cause  some  anosmia.  Primary  degener- 
ative changes  and  excessive  olfactory  stimulation  cause  anosmia. 
There  may  also  be  a  congenital  absence  of  the  nerves.  Anosmia 
occurs  sometimes  as  a  pure  neurosis  in  hysteria  or  in  neurasthenic 
states. 

Diagnosis.—  This  is  made  by  test  odors.  To  test  the  sense  of 
smell,  a  bottle  of  oil  of  cloves  or  of  some  familiar  non-irritating 
odor  may  be  used.  To  detect  quantitative  disturbance  one  may  use 
six  phials  containing  oil  of  cloves,  in  purity  and  in  watery  mixture 
of  1  to  10,  1  to  100,  1  to  1,000,  1  to  10.000,  and  1  to  lOO.uon. 
Special  olfactometers  have  been  devised.  The  sense  of  smell  for 
11 


162  DISEASES    OF   THE    NEKVOUS    SYSTEM. 

any  single  odor  is  lost  in  about  three  minutes,  but  returns  after 
one  minute's  rest. 

Treatment. — For  functional  anosmia,  snuffs  containing  strych- 
nine gr.  A-  and  gum  acacia  3  ij.  can  be  used.  Weak  galvanic  and 
faradic  currents  are  recommended.  Usually  there  is  in  anosmia  a 
local  catarrhal  condition  of  the  nose  which  requires  treatment. 

Hyperosmia  occurs  only  rarely  and  then  in  neurasthenic,  hys- 
terical, or  insane  persons.  In  the  latter  it  is  more  often  a  psychical 
phenomenon  than  a  peripheral  disorder.  Hyperosmia  can  be  cul- 
tivated, and  this  is  done  sometimes  by  the  blind  and  by  those 
engaged  in  certain  pursuits,  such  as  tea  tasting  and  wine  tasting. 

Hallucinations  of  smell  occur  in  the  insane,  as  just  mentioned, 
and  a  few  cases  of  epilepsy  are  reported  in  which  the  cause  was  a 
stench.  When  all  olfactory  sensations  are  disagreeable  the  condi- 
tion is  called  kakosmia. 

Parosmia  is  a  not  infrequent  condition.  In  it  everything 
smells  alike  to  the  patient,  and  the  odor  smelled  is  perhaps  a 
peculiar  or  offensive  one.  This  condition  may  be  due  to  local  dis- 
ease, but  is  often  a  symptom  of  hysteria  or  neurasthenia. 

The    Optic    Nerve. 

Anatomy. — The  optic  nerve  is  not  a  true  peripheral  nerve  but 
a  tract  of  the  brain,  and  it  connects  the  retinal  cells  with  the  brain 
proper.  Like  other  brain  tracts  its  fibres  have  a  myelin  sheath  but 
no  neurilemma.  The  real  origin  of  the  nerve  is  in  the  retina,  just 
as  the  olfactory  nerve  arises  in  the  peripheral  cells  of  the  olfactory 
mucous  membrane  and  the  spinal  sensory  nerves  arise  in  the  spinal 
ganglia. 

The  retina  is  a  nervous  tissue  formed  essentially  of  three  layers 
of  nerve  cells.  From  without  inward  they  are :  the  layer  of  visual 
cells,  the  layer  of  bipolar  cells,  and  the  layer  of  ganglionic  cells. 
This  subdivision  is  shown  in  the  diagram  (Fig.  85).  These  differ- 
ent layers  may  be  subdivided  so  as  to  give  the  following  layers  from 
without  inward : 

1.  The  layer  of  rods  and  cones.  )  Forming  the  layer  of  visuai  ceUs. 

2.  The  external  granular  layer.  )  °  J 

3.  The  external  molecular  layer.  >  Forming  the  layer  of  bipolar  cens. 

4.  Internal  granular  layer.  J  °  J 

5.  Internal  molecular  layer.  I  Forming  the  layer 

6.  Ganglionic  layer,  with  the  fibres  of  the  optic  nerve,  f  of  ganglion  cells 

The  layer  of  visual  cells  is  subdivided,  as  seen  in  the  figure,  into 
that  of  the  rods  and  cones  externally  and  that  of  the  external  gran- 
ular internally.  This  is,  however,  practically  a  layer  made  up 
simply  of  bipolar  nerve  cells  with  prolongations  more  or  less  long 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL    NERVES. 


163 


which  run  to  the  external  surface  of  the  retina  and  there  form  a 
series  of  bodies  known  as  the  rods  and  cones. 

In  the  layer  of  bipolar  cells  are  layers  of  cells  with  processes 
running  horizontally,  and  in  the  internal  molecular  layer  are  larger 
horizontal  cells,  called  by  Cajal  spongioblasts.  There  are  also  in 
the  retina  terminal  arborizations  of  cells  whose  origin  is  ha  the  thal- 
amus, corpora  geniculata,  or  anterior  tubercles.  These  carry  im- 
pulses to  the  retinal  cells  (Fig.  85,  s). 

The  neuraxons  of  the  ganglionic  cells  send  fibres  which  unite  to 
form  the  optic  nerve. 


Fig.  85.— Transverse  Section  of  a  Mammalian  Retina.  A,  Layer  of  rods  and  cones; 
B,  bodies  of  visual  cells  (external  granular);  C,  external  molecular  layer;  E,  layer  of  bi- 
polar cells  (internal  granular);  F.  internal  molecular  layer;  G,  layer  of  ganglionic  cells; 
H.  layer  of  optic-nerve  fibres;  a,  rod;  b,  cone;  c,  body  of  the  cone  cell;  d,  body  of  tlie  rod 
cell;  e,  bipolar  rod  cells;  /,  bipolar  cone  cells:  j,  h,  i,  j,  k,  ganglionic  cells  ramifying  in  the 
various  strata  of  the  internal  molecular  zone;  ?-,  inferior  arborization  of  the  bipolar  rod 
cells,  connecting  with  the  ganglionic  cells;  r,,  inferior  arborization  of  the  bipolar  cone  cells; 
ty  epithelial  or  Muller  cells;  a",  point  of  contact  between  the  rods  and  their  bipolar  cells;  2, 
point  of  contact  between  the  cones  and  their  bipolar  cells:  ft,  centrifugal  nerve  fibre  (Cajal). 


The  optic  nerves  each  contain  about  500,000  fibres.     They  pass 
to  the  optic  chiasm,  where  about  one-third  of  the  fibres  cross,  in 

man.  In  lower  animals  the  decussation  is  greater.  Those  fibres 
which  do  m»t  cross  come  from  the  outer  or  temporal  third  of  the 
retina;  tlc.se  which  do  cross  come  from  the  internal  or  nasal  two- 
thirds.  A  few  fibres  pass  from  one  optic  centre  in  the  hrain  along 
the  posterior  border  of  the  optic  chiasm  to  the  centre  on  the  opposite 
side  (commissure  of  Gudden).*  Alter  leaving  the  chiasm,  the 
fibres  form  the  optic  tract.  The  tract  curves  up  and  back  around 
the  cms  cerebri,  and  divides  into  a  lateral  and  mesial  root. 

*  There  is  still  very  bigh  authority  for  deny  in. g  the  partial  crossing  of  the 
optic  nerve  (Michel,  Kollikcr). 


164  DISEASES    OF    THE    NERVOUS    SYSTEM. 

These  roots  connect  with  the  external  geniculate  body,  the  an- 
terior tubercles  of  the  corpora  quadrigeniina,  and  the  posterior  gan- 
glion of  the  thalamus  or  the  pulvinar.  These  ganglia  are  called 
the  primary  optic  centres.  Through  the  anterior  tubercles  of  the 
corpora  quadrigeniina,  and  by  other  means,  the  optic  nerve  is  con- 
nected with  the  oculomotor  nerve,  and  thus  reflex  movements  of  the 
pupils,  lids,  and  eyeballs  are  brought  about. 

From  these  primary  optic  centres,  fibres  enter  the  posterior  part 
of  the  internal  capsule,  curve  up  and  back  toward  the  occipital 
lobes,  forming  the  optic  radiations  of  Gratiolet. 

They  are  finally  distributed  to  the  cortex  of  the  occipital  lobe, 
and  in  man  chiefly  to  the  cuneus  and  the  parts  about  the  calcarine 
fissure. 

It  will  be  seen  that  each  retina  is  connected  with  the  occipital 
lobe  of  both  hemispheres ;  further,  that  the  outer  or  temporal  half 
of  each  retina  is  connected  with  the  occipital  lobe  of  the  same  hemi- 
sphere, and  the  inner  or  nasal  half  of  each  retina  with  the  occipital 
lobe  of  the  opposite  side.  The  upper  part  of  each  retina  seems  to 
be  connected  with  the  lower  part  of  the  cuneus,  and  vice  versa  (Fig. 
86). 

Other  connections  exist  by  which  the  optic  centres  on  the  two 
sides  are  connected  with  each  other  and  with  other  cranial  nerves  in 
the  medulla. 

The  optic  nerve  is  a  nerve  of  special  sense  of  vision  and  has  no 
other  function  except  that  of  an  excito-reflex  character. 

Diseases  of  the  Optic  Nerve. 

The  optic  nerve  may  be  affected  by  nearly  all  forms  of  patho- 
logical change.  For  the  neurologist,  however,  the  especially  im- 
portant conditions  are  inflammations,  degenerations,  injuries,  and 
functional  disorders.  Inflammation  of  the  nerve,  or  optic  neuritis, 
may  occur  as  a  papillitis  or  inflammation  of  the  head  of  the  nerve, 
a  neuro-retinitis  or  descending  neuritis,  a  perineuritis,  or  a  retro- 
bulbar neuritis.  Perineuritis  is  rare.  Neuro-retinitis  and  papil- 
litis are  closely  associated  clinically  and  pathologically  (Noyes),  so 
that  practically  only  two  forms  of  neuritis  need  be  discussed  sepa- 
rately. 

Papillitis  and  Neuro-retinitis — Etiology. — This  condition 
is  seen  by  neurologists  in  connection  with  brain  tumors,  brain  ab- 
scess, meningitis,  and  occasionally  multiple  neuritis.  The  other 
causes  are  nephritis,  diabetes,  infectious  fevers,  lead,  and  severe 
hemorrhages.  The  disease  occurs  at  all  ages  and  in  both  sexes. 
In  brain  tumors  it  occurs  in  two-thirds  of  the  cases,  and  especially 
often  in  cerebellar  tumors.  It  occurs  in  eighty  per  cent  of  cases  of 
tuberculous  meningitis. 


SEXSORY    NEUROSES    OF    THE    CEREBRO-SPIXAL    XERVES. 


165 


Symptoms. — Subjective  symptoms  are  often  not  present.  The 
vision  may  remain  good  for  a  long  time.  In  other  cases  there  are 
concentric  limitation  of  the  visual  field,  loss  of  color  sense,  and 
scotomata.  For  a  description  of  ophthalmoscopic  changes,  the 
reader  is  referred  to  special  text-books.  It  is  in  this  condition 
that  "  choked  disc, "  which  is  a  papillitis  with  much  serous  infiltra- 
tion, occurs.  The  changes  are  less  striking  in  neuro-retinitis.  The 
disease  may  affect  one  or  both  nerves.  In  brain  disease  both  nerves 
are  usually  involved. 

Pathology  and  Patliologlcal  Anatomy. — The   process  is   usually 


Fig.  8C— The  Optic  Nerve  and  its  Central  Connections  (modified  from 
steiner).  U,  Retina,  dark  on  the  Bide  connected  with  left  hemisphere;  No,  optic  nerve; 
Ch,  chiasm;  Tiro,  optic  tract;  CM,  Meynert's  commissure;  CO,  Sudden's  commissure; 
Tin,,  thalamus;  Cgl,  corpus  genie,  ext.;  ',<"■  corpor.  quad.;  8s,  optic  radiations;  Co,  occip- 
ital cortex;  Lm,  mesial  lemniscus.  '.Tin-  shading  of  the  retina  and  visual  field  should  just 
reach  the  vertical  lines. ) 

subacute  or  chronic.  Congestion,  exudation,  small  hemorrhages, 
and  collections  of  leucocytes  occur.  The  Bheath  of  the  nerve  just 
back  of  the  globe  is  often  distended  with  a  Berous  exudate.  After 
a  time  the  nerve  fibres  atrophy,  connective  tissue  proliferate 

takes  their  place,  and  we  have  a  secondary  optic  atrophy. 


166 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


The  process  is  essentially  peripheral,  but  it  extends  back  with 
lessening  intensity  into  the  trunk  of  the  nerve.  The  purely  me- 
chanical theory  of  neuritis,  that  it  is  due  to  compression,  cannot 
be  accepted  in  the  light  of  modern  pathology.  It  is  probable  that 
the  neuritis  results  from  an  irritating  serous  fluid  which  extends 
down  the  sheath  of  the  nerve,  this  sheath  being  a  prolongation 
of  the  arachnoid  cavity.  Mechanical  causes  lead  to  constriction, 
accumulation  of  the  fluid,  and  compression  of  the  nerve  at  its 
periphery,  and  hence  to  inflammation.  Sometimes,  at  least,  the 
irritating  fluid  contains  microbes  or  microbic  poisons. 


Fig.  87.— Neuro- retinitis  (Jaeger). 

^Retrobulbar  Neuritis. — In  this  disease  the  lesion  lies  chiefly 
behind  the  globe.  Its  causes  are  especially  toxaemia  from  alcohol 
and  tobacco.  It  is  also  due  to  rheumatic  influences,  syphilis,  lead, 
and  diabetes. 

In  the  acute  cases  there  is  usually  rather  rapid  loss  of  sight, 
with  some  pain  and  tenderness.  The  ophthalmoscopic  changes  are 
relatively  slight.  In  chronic  cases,  which  are  usually  toxic  in  origin 
and  due  to  alcohol  or  tobacco,  or  oftenest  to  both,  there  are  color 
scotomata  or  absolute  scotomata  and  amblyopia.  There  is  no  pain. 
The  condition  is  known  as  tobacco  or  alcoholic  amblyopia. 

The  prognosis  of  neuritis  varies  with  the  cause.  If  this  is  re- 
movable, as  in  the  toxaemias,  recovery  is  the  rule.  This  is  a  proof 
that  in  neuritis  the  connective  tissue  is  the  part  chiefly  involved, 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES.       16? 

for  a  destroyed  or  atrophied  optic  nerve  does  not  recover.     In  many 
cases,  however,  atrophy  follows  the  neuritis. 

The  treoAvient  is  based  on  the  cause.  In  acute  cases  one  niay 
use  cups,  salicylates,  the  iodides,  and  mercury;  later,  the  iodides 
and  strychnine.     Perfect  rest  to  the  eyes  should  be  enjoined. 


F:g.  88.— Papillitis,  "Choked  Disc,"  in  a  Case  of  Cerebral  Tumok_ 

Degeneration  of  the  Optic  Nerve,  or  Optic  Atrophy. — 
This  condition  may  be  primary  or  secondary.  Secondary  atrophy 
is  usually  the  result  of  a  neuritis.  I  shall  describe  here  primary 
optic  atrophy. 

Et'wlofjy. — It  occurs  oftener  in  men  than  in  woman  (three  to  one). 
It  occurs  as  part  of  locomotor  ataxia  in  less  than  half  the  cases; 
other  degenerative  diseases  of  the  cord,  like  multiple  sclerosis,  may 
accompany  it.  Next  to  the  spinal  cord,  it  occurs  oftenest  with 
degenerative  diseases  of  the  brain,  such  as  multiple  sclerosis  and 
general  paresis.  Hemorrhages,  alcoholism,  and  lead  may  be  causes- 
It  may  occur  without  known  cause. 

The  symptoms  are  those  of  gradual  decrease  of  acuity  of  vision,, 
concentric  limitation  of  the  visual  field,  loss  of  color  sense,  dilata- 
tion and  immobility  of  the  pupil.  The  sense  of  sight  may  remain 
good  for  a  long  time.  Ophthalmoscopically,  the  nerve  disc  is 
opaque,  grayish,  or  dirty  looking,  and  often  has  a  cup-shaped  or 
"  cupped-disc"  appearance.  The  vessels  are  smaller  and  few  in 
number. 


1G8  DISEASES   OF   THE    NERVOUS   SYSTEM. 

The  pathology  and  pathologteal  anatomy  are  that  of  a  parenchy- 
matous degeneration  with  loss  of  nerve  fibres,  which  are  replaced 
by  connective  tissue. 

The  prognosis  is  almost  uniformly  bad. 

The  treatment  is  that  usually  of  the  cerebral  or  spinal  disease. 
Mercury,  iodides,  strychnine,  phosphorus,  and  iron  are  given.  Warm 
baths  and  salicylate  of  soda  sometimes  have  a  temporarily  good 
effect.  Strychnine  in  physiological  doses  gives,  however,  the  best 
symptomatic  results.  Electricity  is  not  of  any  use.  Stretching  the 
nerve  does  no  good.  Eserine,  pilocarpine,  and  santonin,  or  nitrate 
of  silver  may  be  tried. 

The  optio.  nerves  and  their  primary  and  cortical  centres  are  sub- 
ject to  various  other  diseases.  So  far  as  these  are  organic,  they 
will  be  described  in  detail  under  the  head  of  brain  diseases.  But 
there  are  certain  symptoms  often  of  functional  origin  which  are 
best  described  here.  These  are:  (1)  Amblyopia  and  amaurosis; 
(2)  retinal  hyperaestbesia  and  dysesthesia ;   (3)  hemianopsia. 

Amblyopia  and  Amaurosis. — Amblyopia  is  a  partial  loss  or 
dimness  of  vision,  there  being  no  observable  lesion  of  the  eye,  or 
its  nerves.  Amaurosis  is  a  total  loss  of  vision,  also  without  ob- 
servable cause. 

Etiology.  — The  causes  are  injuries  and  shocks,  hysteria,  migraine, 
concussion  of  the  brain,  lightning  stroke,  and  severe  hemorrhages. 
There  are  also  certain  toxic  causes,  chiefly  alcohol  and  tobacco, 
quinine,  and  salicylic  acid.  Other  causes  are  glycosuria,  uraemia, 
and  reflex  irritations,  especially  of  the  trigeminal  nerve.  Night 
blindness  and  snow  blindness  are  forms  of  functional  amblyopia. 

The  symptoms  are  diminution  or  loss  of  vision,  usually  sudden, 
temporary,  and  involving  both  eyes.  Amblyopia  in  hysteria  is 
usually  greater  in  one  eye  and  associated  with  concentric  limitation 
of  the  visual  field  and  disturbance  of  color  sense. 

Underlying  amblyopia  there  may  be  minute  hemorrhages  in 
the  brain,  causing  temporary  pressure,  or  a  vascular  spasm,  causing 
anaemia. 

The  pro  gnosis  is  usually  good. 

The  treatment  is  purely  a  causal  one.  In  most  cases  one  must 
examine  for  drug  poison,  uraemia,  diabetes,  migraine,  or  a  hemor- 
rhage. 

Ketinal  or  ocular  hyperesthesia  is  a  condition  in  which 
the  eye  is  abnormally  sensitive  to  light.  It  may  be  due  to  expo- 
sure to  extreme  light  or  to  seclusion  in  a  dark  room.  The  neu- 
rologist sees  it  oftenest  as  a  symptom  of  hysteria  (vide  Hysteria) 
and  neurasthenia  and  perhaps  in  hypnotic  states.     It  occurs  in  my- 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL    NERVES. 


1(59 


driasis  and  albinism.  It  is  not  to  be  confounded  with  photophobia 
due  to  irritation  of  the  conjunctiva. 

Nyctalopia,  or  the  condition  of  seeing  better  in  a  dim  light,  is  a 
form  of  the  disease. 

Hemianopsia,  or  half-sightedness,  or  hemianopia,  a  condition 
in  which  there  is  a  blindness  of  one-half  the  visual  field,  may  be 
due  to  a  functional  or  organic  disorder  of  the  nerve  or  its  centres. 
It  is  a  symptom  of  many  lesions  and  conditions,  and  can  be  de- 
scribed only  generally  here. 


Fig. 


-Showing  Lateral  Homonymous  Hemianopsia.    This  is  not  quite  complete,  there 
being  a  space  on  the  blind  side  where  the  patient  can  see  (Noyes  I. 


Etiology. — Its  principal  functional  causes  are  migraine,  lithae- 
mia,  gout.  Its  organic  causes  are  tumors,  inflammations,  soften- 
ings, or  hemorrhages  involving  part  of  the  optic*  nerve  or  its  central 
connections. 

Symptoms. — Various  descriptive  terms  are  used  to  indicate  tin- 
character  of  the  hemianopsia.  In  lateral  hemianopsia  a  vertical 
half  of  the  field  is  involved.  In  lateral  homonymous  hemianopsia 
there  is  half-blindness  on  the  left  or  right  side  of  each  eye,  as  the 
case  may  be  (Fig.  89).  In  temporal  hemianopsia  the  outer  halves 
of  tin- eyes,  and  m  nasal  the  inner  halves,  are  involved.  The  upper 
or  lower  segments,  or  irregular  segments  of  the  visual  field  may 
be  involved. 

These  various  forms  of  hemianopsia  depend  upon  the  location  of 
the  lesion  which  cuts  into  and  destroys  the  optic  fibres  in  their 
course  from  the  eye  to  the  visual  centre  in  the  occipital  cortex. 
The  mechanism  will  he  understood  when  it  is  remembered  that  each 
occipital  lobe  is  supplied  by  nerve  fibres  ham  one-half  of  the  retina 
of  each  eye.  A  cut  shows  this  better  than  any  description  i  Fig. 
86).  In  temporal  hemianopsia  the  lesion  must  he  at  Ch,  in  front 
of   the    chiasm.       In    bilateral    nasal  hemianopsia  it   must   be   double 


170  DISEASES    OF   THE    NERVOUS    SYSTEM. 

and  at  N  and  X  .  In  lateral  hemianopsia  the  lesion  must  lie  farther 
back  than  the  chiasm,  in  the  tract,  the  primary  centres,  the  optic 
radiations,  or  occipital  lobes. 

In  hemianopsia  from  disease  of  the  nerve  as  far  back  as  and  in- 
cluding the  primary  centres  in  the  optic  thalamus  and  corpora 
quadrigemina  there  is  a  loss  of  light  reflex  when  a  ray  of  light  is 
thrown  upon  the  blind  side  of  the  retina,  but  the  pupil  still  con- 
tracts when  light  is  thrown  on  the  sensitive  side  of  the  retina. 
This  phenomenon  is  called  "Wernicke's  hemiopic  pupillary  reac- 
tion." If  in  hemianopsia  the  light  reflex  is  preserved,  the  lesion 
is  back  of  the  primary  centres  and  involves  the  optic  radiations  or 
cortex. 

A  test  for  the  condition  of  hemianopsia  in  its  early  stage,  and 
one  that  is  useful  in  stupid  or  partially  comatose  patients,  is  the 
following :  When  the  finger  is  suddenly  brought  in  front  of  the  eye 
on  the  sound  side,  there  is  a  wink ;  if  brought  in  front  from  the 
blind  side,  the  orbicularis  does  not  contract. 

Hemianopsia  is  almost  always  the  sign  of  organic  disease.  It 
is  not  found  in  hysteria,  but  does  occur  in  migraine  and  lithsemia. 
It  is  best  made  out  and  recorded  by  means  of  the  perimeter. 

Its  course  and  treatment  depend  upon  the  cause. 

Sensory  Neuroses  of  the  Trigeminal  Nerve. 

Anatomy. — The  trigeminus  or  fifth  nerve  is  one  of  the  most  ex- 
tensively distributed  and  most  delicately  sensitive  nerves  of  the  body. 
Its  sensory  branches  represent  the  atrophied  and  lost  sensory  roots 
of  the  third,  fourth,  sixth,  seventh,  and  twelfth  cranial  nerves 
(Gaskill).  The  trigeminal  nerve  is  a  mixed  nerve.  It  has  two 
nuclei  of  origin:  a  central  nucleus  for  the  motor  part,  and  a 
peripheral  nucleus  for  the  sensory  part.  The  motor  nucleus  has 
two  parts:  a  chief  nucleus  lying  deeply  in  the  substance  of  the 
pons  Varolii,  and  an  accessory  nucleus,  which  consists  of  a  long 
tract  of  gray  matter,  known  as  the  descending  root  and  lying  in  the 
upper  part  of  the  dorsal  portion  of  the  pons.  It  passes  down  along 
the  side  of  the  aqueduct  of  Sylvius.  There  has  been  much  discus- 
sion as  to  the  exact  function  of  this  root  or  nucleus,  but  the  most 
recent  studies  have  shown  quite  conclusively  that  it  is  motor  in 
function  (Kolliker,  Cajal).  The  sensory  root  of  the  trigeminal  has 
its  origin  in  the  Gasserian  ganglion,  which  is  composed  of  unipolar 
cells,  like  those  of  the  spinal  ganglia.  The  axis-cylinder  processes 
of  these  cells  bifurcate;  the  external  branches  pass  outward  and 
become  part  of  the  peripheral  sensory  root;  the  internal  branches 
pass  into  the  substance  of  the  pons,  and  there  give  off  ascending  and 
descending  branches.  The  ascending  branches  are  short,  and  pass 
to  a  terminal  nucleus,    known  heretofore   as  the  sensory  nucleus 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL    NERVES.      171 

of  the  trigeminal.  The  descending  branches  pass  down  to  the 
pons  and  medulla,  as  far  as  the  cervical  part  of  the  spinal  cord. 
In  their  course  they  give  off  terminal  filaments,  which  come  in  rela- 
tion with  sensory  nerve  cells,  and  the  whole  forms  a  column  of 
matter,  known  as  the  ascending  root  of  the  trigeminus. 


Fig.  90. — Showing  the  Mode  of  Origin'  of  the  Trigeminal  Nerve,  and  thb 
Relations  of  th;-:  Motor  and  Sensory  Roots,  rac.  cer.  is  the  cerebral  or  motor  root 
and  its  fibres  go  to  the  Inferior  maxillary  branch;  rac.  spin,  is  the  spinal  or  ascending' 
root.  The  cut  shows  the  Gasserian  ganglion  giving  origin  to  the  sensory  fibres  (Van 
Gehuchten). 

The  nuclei  of  the  trigeminus  reach  the  whole  length  of  the  pons 
and  medulla,  and  are  coextensive  with  the  origin  of  all  the  other 
cranial  nerves  (Fig.  91).  Hence  the  frequency  with  which  its  dis- 
orders are  complicated  with  those  of  these  nerves.  Its  cortical 
origin  is  probably  in  the  lower  part  of  the  pre-  and  post-central  con- 
volutions. 

The  trigeminus  supplies  sensation  to  the  face,  conjunctivae,  nose, 
the  frontal  and  maxillary  sinuses,  the  teeth,  the  palate,  tongue, 
and  part  of  the  upper  pharynx;  also  to  the  scalp  as  far  back  as  the 
vertex,  and  to  the  external  auditory  meatus  (Fig.  93).  The  distri- 
bution is  not  always  the  same  and  is  helped  by  fibres  from  the  cer- 
vical nerves.  Entire  removal  of  the  <  lasserian  ganglion  in  man  may 
give,  for  example,  anaesthesia  only  over  the  areas  shown  in  Fig.  92, 
in  which  anaesthesia  is  not  complete  in  areas  /  or  a.  It  gives  sensa- 
tion also  to  the  anterior  three-fourths  of  the  dura  mater,  the  falx, 
and  probably  the  tentorium.    The  pia  and  arachnoid  are  not  sensitive. 


172 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


The  posterior  fossa  and  the  occipital  part  of  the  dura  rnater  are  sup- 
plied by  the  vagus.  The  trigeminus  also  supplies  the  above-named 
parts  with  trophic,  vasomotor,  and  secretory  fibres.  The  vasomotor 
fibres  are  brought  to  it,  in  part,  from  the  medulla  and  cervical  spinal 


Fig.  91.— Showing  the  Origin  ok  the  Cranial  Nerves  and  the  Extent  of  the  Origin 
of  the  Trigeminus  (Edinger). 


cord  via  the  sympathetic ;  the  secretory  fibres  have  the  same  origin. 
An  exception  is  to  be  made  of  the  lacrymal  secretory  fibres  which 
are  brought  by  the  motor  nerves  of  the  eyeball.  The  opinion,  based 
largely    on  physiological    experiment,    that   the    trigeminus  sends 


FIG. 93.    Showing  Area  of  An.-esthesia  after  Removal  of  Uasserian  Ganglion  (Krause). 


trophic  fibres  to  the  conjunctivae  and  cornea,  is  denied  by  Krause, 
who  reports  many  successful  cases  of  entire  extirpation  of  the  Gas- 
serian  ganglion  without  any  inflammation  of  the  eye  following. 

The  trigeminus  supplies  motion  to  the  muscles  of  mastication, 
viz.,  the  two  pterygoids,  the  temporal,  masseter,  mylo-hyoid,  and 
anterior  belly  of  the  digastric.  The  sensory  neuroses  of  this  nerve 
are  neuralgia,  parsesthesia,  and  anaesthesia. 


SEXSORY    NEUROSES    OF    THE    CEREBRO-SPIXAL    NERVES.        173 

Neuralgias  of  the  Trigeminus. — The  trigeminal  nerve  is  sub- 
ject to  tAvo  types  of  neuralgia,  viz.  : 

1.  The  symptomatic  form. 

2.  Tic  douloureux. 

1.   The  symptomatic  neuralgias  are  by  far  the  most  frequent. 

They  are  called  supra-orbital,  infra-orbital  or  supraniaxillary, 
inframaxillary  or  dental,  and  mixed  forms.  The  most  common  type 
is  the  supra-orbital ;  next,  the  mixed  form. 

Etiology* — The  female  sex  is  oftenest  affected;  most  cases  are 
seen  in  the  first  half  of  life;  most  attacks  occur  in  the  winter  and 
spring.  The  left  side  is  oftener  affected.  The  second  and  third 
branches  of  the  fifth  nerve  are  most  susceptible  to  rheumatic  influ- 


Fig.  93.  —Showing  the  Distribution  op  the  Sensory  Nerves  of  the  Face.  /,  IF,  I  FT, 
First,  second,  and  third  branches  <>f  tin'  fifth.  The  shaded  part  is  supplied  by  the  cervical 
nerves;  2  C.a.br.,  second  cervical  anterior  branch;  ~  Cp.br.,  Becond  cervical  posterior 
branch. 


ences,  the  first  branch  to  malaria]  and  septic  poisons.  Dental  dis- 
orders naturally  are  frequent  factors  in  neuralgia  of  the  second  and 
third  branches.  Anaemia,  exposure,  child-bearing,  and  other  de- 
pressing influences  are  factors  in  causing  these  neuralgias.  Ocular 
ami  nasal  disease  may  cause  pais  in  the  supra-orbital  nerve.  Gout, 
diabetes,  syphilis^  malaria,  hysteria,  epilepsy,  trauma,  rheumatism, 
all  may  be  factors  in  causing  trigeminal  neuralgias. 

Symptom*.     The  pains  of  trigeminal  neuralgia  are  sharp  and  in- 
tense, with  exacerbations  and  remissions.      The   pain  often  lasl 
days  without  entirely  ceasing.      It  then  ^<>es  away  and  may  not  return 


174  DISEASES   OF   THE   NERVOUS   SYSTEM. 

for  a  long  time.  The  characteristic  of  neuralgia  is  that  it  stays  till 
its  cause  is  removed.  In  supra-orbital  neuralgia  there  is  sometimes 
great  oedema  of  the  lids  and  the  parts  about,  together  with  suffusion 
of  the  eyes.  There  are  tender  points  over  the  course  of  the  nerves. 
The  tender  points  in  supra-orbital  neuralgia  are  supra-orbital,  pal- 
pebral, and  nasal ;  in  infra-orbital  neuralgia,  nasal,  malar,  and 
gingival;  in  infra-maxillary  neuralgia,  inferior  dental  and  tem- 
poral. In  the  mixed  forms  Ave  find  various  combinations  of  the 
above.  There  is  often  also  a  tender  point  over  the  parietal  emi- 
nence and  vertex. 

The  pain  may  radiate  to  the  ear  or  occiput,  or  it  may  be  located 
in  the  orbit.  .  Dental  irritation  may  also  cause  an  otalgia  or  a 
neuralgia  in  the  upper  branches  of  the  fifth. 

There  is  sometimes  a  dilatation  of  the  pupil,  and  in  severe  cases 
a  reflex  facial  spasm  occurs. 

Tic  Douloureux  (Prosopalgia,  FothergilV s  Neuralgia,  Epilepti- 
form Neuralgia). — Tic  douloureux  is  a  special  form  of  trigeminal 
neuralgia  occurring  in  middle  or  advanced  life,  unusually  severe  in 
its  symptoms  and  obstinate  in  its  course.  It  ought  to  be  distin- 
guished sharply  from  the  ordinary  forms  of  trigeminal  neuralgia. 
These  latter  are  symptomatic  pains  almost  altogether;  while  tic 
douloureux  is  a  special  disorder,  dependent  upon  changes  in  the 
nerve  itself. 

Etiology. — It  occurs,  as  a  rule,  in  persons  who  are  over  forty, 
and  is  seen  in  the  very  aged.  It  is,  indeed,  almost  the  only  neu- 
ralgia which  old  people  have.  It  is  brought  on  by  exposure,  over- 
work, and  depressing  influences;  sometimes,  perhaps,  by  local  dis- 
eases of  the  teeth  and  jaws.  It  occurs  in  men  and  women  in  about 
equal  frequency,  in  my  experience.  Other  observers  find  it  oftener 
in  women. 

Symptoms. — It  is  characterized  by  intense  darting  pains,  which 
usually  start  in  the  upper  lip  and  by  the  side  of  the  nose.  From 
here  they  radiate  through  the  teeth  or  into  the  eye  and  over  the 
temple,  brow,  and  head.  They  are  confined  to  one  side  of  the  head. 
During  a  paroxysm  the  face  usually  flushes,  the  eyes  water,  the 
nose  runs,  and  the  patient  assumes  an  expression  of  the  greatest 
agony.  The  attack  lasts  for  a  few  minutes,  then  becomes  somewhat 
less,  but  the  pain  rarely  ceases  entirely.  A  breath  of  cold  air,  speak- 
ing, eating,  putting  out  the  tongue — all  bring  on  paroxysms.  The 
pains  are  worse  in  winter  and  often  become  less  or  cease  during 
summer.  Occasionally  they  come  on  for  a  few  months  every  year, 
usually  during  the  spring.  The  pains  are  always  limited  to  one 
side  of  the  face  and  are  centred  chiefly  in  one  branch  of  the  nerve. 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES.       175 

oftenest  in  the  supraniaxillary  and  next  in  the  inframaxillary. 
They  may  spread  so  as  to  involve  the  whole  of  one  side  of  the  face 
and  tongue. 

Spasmodic  movements  of  the  face,  tongue,  or  jaws  may  be 
associated  with  the  pain. 

Examination  rarely  reveals  any  objective  trouble,  but  in  a  few 
cases  some  anaesthesia  may  be  noted. 

Pathology. — The  disease  is  usually  a  degenerative  one,  and 
probably  is  due  to  irritative  and  atrophic  processes  occurring  in  the 
nerve  and  its  ganglion.  A  low  grade  of  neuritis,  perhaps  from 
alveolar  disease,  has  been  found  sometimes,  but  as  a  rule  the  nerve 
does  not  appear  much  changed.  The  arteries  supplying  the  nerve, 
however,  often  undergo  the  changes  of  endarteritis,  their  calibre  is 
much  lessened,  and  the  nerve  cannot  get  its  proper  supply  of  blood. 
Thus  an  obliterative  arteritis  underlies  some  cases  of  the  disease. 

Treatment. — In  cases  which  occur  in  old  people,  the  use  of  nitro- 
glycerin given  in  doses  of  gr.  yi^  q.  2  h.  sometimes  has  a  happy 
effect.  A  very  good  remedy  is  crystalline  aconitia  given  in  doses 
of  gr.  ^-i-y-  until  its  physiological  effect  is  obtained.  Besides  these 
measures,  galvanism  daily,  iodide  of  potassium  in  large  doses, 
gelsemium,  eroton  chloral,  codeine,  external  applications  of  menthol, 
freezing  with  chloride  of  methyl,  and  heat — all  may  be  found  use- 
ful. The  common  practice  of  pulling  out  all  the  teeth  is  almost 
always  unsuccessful,  and  ought  not  to  be  undertaken  without 
specially  good  reason.  Tonics  containing  iron,  phosphorus,  quinine, 
or  arsenic  are  generally  helpful,  and  should  always  be  given  after  a 
course  of  specifics.  In  younger  patients  the  remedies  recommended 
under  the  head  of  Migraine  and  Headache  may  be  given.  Change 
to  a  warm,  equable  climate  may  be  tried;  it  is  not  a  certain  resource. 
I  have  found  that  in  cases  not  of  over  four  or  five  years'  duration, 
rest  in  bed  with  massive  doses  of  strychnine  sometimes  effects  striking 
cures.  The  drug  should  be  given  hypodermically  in  doses  of  gr.  ^ 
once  daily,  gradually  increased  until  gr.  ^  or  1-  is  reached.  This  is 
repeated  four  clays  and  then  the  amount  gradually  reduced.  The 
patient  must  be  kept  rigidly  quiet  and  the  full  course  persisted  in. 
After  a  month  iodide  of  potassium  and  iron  are  given.  The  treatment 
may  have  to  be  repeated  with  lessened  rigor.  The  treatment  by 
large  doses  of  opium,  gr.  iii.  to  vi.  daily,  is  uncertain  and  often  dan- 
gerous. 

Finally,  surgical  interference  may  be  necessary.  The  removal 
of  the  nerve  at  as  deep  a  point  as  possible  is  the  only  operation  to 
be  seriously  entertained.  This  sometimes  causes  cure,  but,  as  a 
rule,  the  pain  comes  back  in  six  or  twelve  months.     Even  such  a 


176  DISEASES   OF   THE   NERVOUS   SYSTEM. 

respite,  however,  is  often  gladly  seized  upon.  Removal  of  the 
Gasserian  ganglion  has  been  attempted  with  success.  Ligature  of 
the  common  carotid  has  been  tried  also,  but  of  late  years  the  opera- 
tion has  been  generally  abandond.  Simple  drilling  out  of  the  infra- 
orbital nerve  with  a  dental  probe  made  of  piano  wire  has  given  long 
relief. 

There  are  numerous  methods  of  operating  upon  the  different 
branches  of  the  trigeminus.  For  buccal  neuralgia,  Zuckerkancll 
has  devised  a  method.  For  superior  maxillary  neuralgia,  the 
method  of  Carnochan,  modified  by  Abbe,  is,  in  my  opinion,  the 
best.  Others  favor  Langenbeck's  method.  Ullmann,  Mikulicz, 
Obalinski,  and  many  others  have  devised  special  methods. 

Hartley,  of  New  York,  has  devised  an  operation  by  which  he 
enters  the  middle  fossa  through  an  opening  in  the  temporal  bone, 
thus  reaching  the  root  of  the  nerve.  Rose,  Krause,  and  others  have 
reported  many  successes  following  this  rather  serious  operation. 

Trigeminal  Paresthesia. — Sometimes  persons  suffer  from 
peculiar  numbness,  thrilling,  or  formication  in  the  course  of  the 
trigeminus.  The  sensation  may  be  nearly  constant  and  excessively 
annoying.     It  never  amounts  to  actual  pain. 

It  occurs  in  anaemic,  nervous,  and  hysterical  persons.  It  is  to 
be  regarded  as  an  abortive  form  of  neuralgia,  and  so  treated. 

Trigeminal  Anesthesia. — This  occurs  from  various  patho- 
logical lesions  in  the  course  of  the  nerve  or  in  its  nuclei.  The  most 
common  organic  cause  is  syphilitic  disease  of  the  membranes  at  the 
base  of  the  brain.  Trigeminal  anaesthesia  occurs  together  with  an- 
aesthesia of  other  areas  in  hysteria  and  in  organic  disease  of  the 
nerve  centres.  It  is  sometimes  noted  in  tic  douloureux  and  facial 
hemiatrophy. 

.Hkrpes,  flushing,  pallor,  lacrymation,  salivation,  are  all  symp- 
toms of  disturbance  of  the  trophic,  vasomotor,  and  secretory  fibres 
running  in  the  trigeminal  nerve.  They  are  usually,  if  pathological, 
only  concomitant  symptoms  of  other  diseases. 

Headache  (Cephalalgia). 

Headache  is  the  name  given  to  attacks  of  diffuse  pain  affect- 
ing different  parts  of  the  head  and  not  confined  to  the  tract  of  a 
particular  nerve.  It  usually  comes  on  in  paroxysms  at  various 
intervals,  but  may  be  continuous. 

Etiology, — Headache  is  the  most  common  of  nervous  symptoms. 
Ten  to  fifteen  per  cent  of  school  children,  twenty-five  per  cent  of 
men,  and  over  fifty  per  cent  of  women  are  subject  to  it  more  or  less, 


.      SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES.       177 

though  this  proportion  would  be  much  reduced  if  migraine  were 
excluded  from  statistics.  « 

The  headache  ages  are  from  ten  to  twenty -five  and  thirty-five  to 
forty-five;  most  cases  occur  between  the  ages  of  eight  and  twenty- 
five,  especially  in  females.  The  number  of  headaches  increaaea 
gradually  from  the  period  live  to  ten  years  up  to  the  period   fifteen 


Fig.  94.— Showing  the  motor  and  sensory  Nekves  of  the  Face  (Merkel) 


to  twenty,  then  falls  till  the  thirty-fifth  year,  and  rises  again  till 
about  the  age  of  forty.  Early  childhood  and  declining  age  are 
practically  exempt  from  chronic  functional  headaches.  Women 
suffer  from  it  more  than  men  in  the  proportion  of  about  three  to 
one.  It  is  more  frequent  in  city  populations  ami  among  the 
wealthier  classes.  Headaches  are  more  common  in  the  spring  and 
fall  and  in  temperate  climates.  Headaches  may  be  classed,  in 
accordance  with  their  causes,  as  billows: 

1.  Hemic  or  autotoxic  causes,  in  which  Impoverished  or  dis- 
ordered blood  is  brought  to  the  brain,  as  in  (a)  anaemia  and  conges- 
tion; (Jj)  diathetic  states:  gout,  rheumatism,  diabetes,  anemia;  (c) 
infections :  malaria,  fevers. 

2.  Toxic  causes:  lead,  alcohol,  tobacco,  etc. 

3.  Neuropathic  states  :  epilepsy,  neurasthenia,  hysteria,  neuritis. 

4.  Keflex  causes:  ocular,  nasopharyngeal,  auditory,  dyspeptic, 
sexual. 

12 


178 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


5.  Organic  disease,  including  arterio-sclerosis,  syphilis,  tumors, 
meningitis,  and  diseases  of  the  cranial  bones.  Very  frequently 
several  causes  act  together.  The  anaemic,  dyspeptic,  ocular,  and 
neurasthenic  are  the  common  forms  of  chronic  and  recurrent  head- 
ache. 

Edinger  thinks  that  a  large  percentage  of  chronic  headaches  are 
due  to  the  presence  of  certain  nodules  situated  near  the  origin  of 
the  muscles  of  the  back  of  the  head.  The  location  of  these  is  in- 
dicated in  Fig.  95.     Massage  by  removing  these  relieves  the  head- 


FIG.  95.— LOCATION  OF  HEADACHE  NODULES  ACCORDING  TO   EDINGER. 


ache.  I  have  not  found  these  often,  and  doubt  if  they  have  so 
much  importance,  but  their  existence  and  possible  influence  should 
be  borne  in  mind,  especially  in  gouty  subjects. 

Symptomatology. — Headaches  may  be  classed  in  accordance  with 
their  location  and  the  character  of  the  pain.  We  have  accordingly : 
1,  frontal  headaches;  2,  occipital  headaches;  3,  parietal  and  tem- 
poral headaches;  4,  vertical  headaches;  5,  diffuse  headaches  and 
various  combinations  of  the  above. 

The  most  common  form  of  headache  is  the  frontal,  next  the 
fronto-occipital  or  diffuse,  next  the  vertical,  and  then  the  occipital. 

The  kind  of  pain  differs  with  different  persons  and  with  differ- 
ent causes.     We  have:  1,  pulsating,  throbbing  headache;  2,  dull, 


SENSORY    NEUROSES    OF    THE    CEREBRO-SPINAL    NERVES.       179 


heavy  headache ;  3,  constrictive,  squeezing,  pressing  headache;  4, 
hot,  burning,  sore  sensations ;  5,  sharp,  boring  pains. 

The  first  form  characterizes  headaches  with  vasomotor  disturb- 
ances, and  usually  indicates  migraine. 

The  second  is  usually  of  a  toxic  or  dyspeptic  type.  The  third 
is  found  in  the  neurotic  and  neurasthenic.  The  fourth  in  rheu- 
matic and  anaemic  cases.  The  fifth  in  hysterical,  neurotic,  and 
epileptic  cases. 

The  accompanying  diagram  shows  some  of  the  relations  of 
localized  pain  to  the  cause.  A  large  experience  both  in  my  own 
practice  and  in  that  of  others  shows  it  to  be  approximately  correct. 

Headaches  may  continue  for  a  day  or  may  last  for  weeks  or 
months.     Some  persons  have  headaches  only  when  constipated  or 


Constipation. 
Caries  of  incisor 


Error  of  eye-refraction.. 


Gastric  dyspepsia ; 
cured  by  acids 


„,,Eye. 
/„,  Decayed  teeth. 


-Ay^l-^Pharyngitis. 
'  .*'     Otitis  media. 


Fig.  9fi.— Showing  the  Location  op  the  Pain  in  Headaches  from  Different  Causes. 

bilious,  or  when  they  have  an  attack  of  indigestion.  Others  suffer 
from  a  little  pain  nearly  all  the  time,  exacerbations  occurring  at 
various  periods.  Neurasthenic  and  ocular  headaches  are  generally 
of  this  type.  When  headaches  are  persistent,  examination  should 
be  made  of  the  eyes,  of  the  nose  and  sinuses ;  the  patient  should  be 
questioned  as  to  syphilis,  the  continuous  use  of  tobacco,  and  chronic 
dyspepsia.  The  possibility  of  brain  tumor,  of  pachymeningitis 
from  blows,  or  sunstroke  or  chronic  alcoholism  should  be  considered. 

The  persistent  headaches  not  relieved  by  ordinary  treatment  are 
due  to  eye  trouble,  anaemia,  neurasthenia  or  spinal  irritation,  rheu- 
matic nodules,  syphilis,  or  pachymeningitis.  Eye  strain  may  cans.' 
true  migraine  or  ordinary  headache.  Eye-strain  headache  is  usu- 
ally associated  with  some  weakness  of  eyesight  and  pains  and  dis- 
comfort about  the  globe,  besides  severer  pains  at  times  in  the  brow 
or  occiput.  The  cause  of  the  eye  strain  is  usually  astigmatism  and 
hypermetropia.  Occasionally  it  is  due  to  weakness  or  lack  of  bal- 
ance of  the  eye  muscles. 

Headaches  may  occur  regularly  every  morning  on  awaking. 
They  are  called  morning  headaches,  and  are  a  symptom  of  neuras- 
thenia and  lithsemia.     They  occur  oftenest  in  middle  life. 


180  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Symptoms  Associated  with  Headache, — The  symptoms  oftenest 
associated  with  chronic  and  recurrent  headaches  are  vertigo,  som- 
nolence, sensations  of  heat  and  pressure  (cerebral  paresthesias),  and 
nausea.  Vertigo  goes  oftenest  with  headaches  of  dyspeptic  origin; 
some  of  the  so-called  bilious  headaches  of  early  life  develop  later 
into  attacks  of  vertigo;  this  symptom  often  occurs  with  frontal 
headaches.  Somnolence  occurs  oftenest  with  anaemic  and  malarial 
headaches  ;  it  may  develop  also  with  syphilitic  head  pains.  Nausea 
I  have  found  oftenest  with  occipital  headaches. 

Pathology^ — Headaches  are  to  be  distinguished  from  neuralgias 
and  from  a  special  and  common  form  of  head  pain  known  as 
migraine. 

Headaches  are  diffused  pains  caused,  as  a  rule,  by  irritations 
located  in  or  referred  to  the  peripheral  ends  of  the  fifth  nerve. 
Their  seat  is  usually  within  the  skull. 

Neuralgias,  on  the  other  hand,  are  caused  by  irritations  of  the 
ganglia  or  trunks  of  these  nerves.  The  pains  are  local  and  confined 
to  the  single  branches  of  the  nerve. 

Migraine  is  a  periodical  neurosis  in  which  there  is  a  discharge  of 
nerve  force,  not  only  affecting  the  trigeminus,  but  often  other  cranial 
nerves  as  well  as  sympathetic  fibres.  It  is  a  general  disease  of 
which  the  headache  is  only  one  symptom. 

The  nerves  of  the  dura  mater  are  those  most  involved  in  head- 
ache. Headaches,  when  occipital,  involve  the  sensory  fibres  of  the 
vagus  and  the  upper  four  cervical  nerves.  There  is  no  anatomical 
change  in  the  nerves  except  in  organic  headaches.  But  in  many 
cases  the  membranes  of  the  brain  and  their  sensory  nerves  are 
congested  or  anaemic. 

Diagnosis. — No  symptom  requires  more  careful  investigation  as 
to  its  cause  than  that  of  headache.  The  diagnosis  is  always  to  be 
made,  not  of  this  symptom,  but  of  its  cause.  Most  of  the  foregoing 
description  accordingly  refers  to  etiology.  It  may  be  quite  posi- 
tively affirmed  that  headaches  which  persist  for  months,  are  worse 
in  the  day,  and  leave  the  patient  able  to  sleep  at  night,  to  recur 
on  waking,  are  exhaustion  pains  and  are  due  to  a  neurasthenic  state. 
Chronic  headaches,  worse  at  night,  are  usually  of  specific  or  organic 
origin . 

It  is  important,  however,  to  decide  whether  the  case  is  one  of 
migraine,  or  neuralgia,  or  headache.  Headache  is  usually  diffuse 
and  bilateral.  It  is  more  or  less  persistent.  Migraine  comes  on 
paroxysmally,  lasts  a  short  time,  and  then  leaves  the  patient  feeling 
perfectly  well  or  even  better  than  ever.  Migraine  is  often  accom- 
panied with  nausea,  flashes  of  light,  strong  pulsations  of  the  head, 


SENSORY    NEUROSES   OF    THE    CEREBRO-SPINAL    NERVES,        181 

vertigo,  pallor,  or,  more  rarely,  congestion  of  the  face.  Neuralgic 
pains  are  sharp  and  shooting;  they  run  along  the  tract  of  the  nerve, 
and  often  are  associated  with  suffusion  of  the  eye  and  oedema. 
Tender  points  are  felt. 

Treatment. — The  constitutional  treatment  is  based  upon  the 
etiology.  Eegulation  of  diet  and  digestion,  securing  a  regular 
movement  of  the  boAvels,  attention  to  ocidar  troubles,  abstention 
from  tobacco  and  alcohol  and  overwork  are  the  important  points 
requiring  attention.  Best  is  the  important  point  to  attend  to,  as  in 
almost  all  painful  neuroses. 

The  symptomatic  treatment  consists  in  giving  antipyrin,  anti- 
febrin,  phenacetin,  salicylate  of  sodium,  caffeine,  muriate  of  ammo- 
nia, and  sometimes  morphine  or  codeine,  and  bromide  of  ammonium. 

Antipyrin  can  be  given  in  doses  of  gr.  v.  every  twenty  minutes 
till  three  or  four  doses  are  taken.  Phenacetin  often  needs  to  be 
given  in  large  doses  of  ten  or  even  twenty  grains.  Antifebrin  is 
less  trustworthy  and  must  be  given  in  small  doses.  Exalgin  is  not 
a  very  good  or  safe  remedy.  It  may  be  tried  in  doses  of  gr.  iij.  to 
gr.  v.  Muriate  of  ammonia  is  an  excellent  remedy  given  in  very 
large  doses,  3  SB.  to  Z  i->  well  diluted.  Menthol  in  doses  of  gr. 
v.  to  gr.  x.  in  hot  water  sometimes  stops  headaches.  In  headaches 
from  anaemia,  caffeine  and  ammonium  muriate  are  best.  In  head- 
ache from  nervous  exhaustion,  similar  stimulating  anodynes  are 
usually  most  efficacious.  Combinations  of  caffeine  citrate  and  salicy- 
late of  sodium  or  benzoate  of  sodium  are  often  better  than  the  single 
drug.  Caffeine  in  any  case  must  lie  given  in  larger  doses  than  is  or- 
dinarily done,  ■/./'.,  gr.  iv.  or  v.  Local  applications  of  a  twenty- 
per-cent  solution  of  menthol,  the  ice  bag,  cloths  wrung  out  in  hot 
water,  or  a  piece  of  sheet  lint  snaked  in  chloroform  liniment  two 
parts  and  tincture  of  aconite  one  part  are  efficacious  meas 
cathartic,  rest  in  a  darkened  room,  light  diet — all  these  are  measures 
which  many  patients  themselves  learn  t<>  adopt. 

Finally,  in  headache  from  organic  disease  we  have  often  to 
resort  to  iodide  of  potassium,  mercury,  and  the  use  of  some  prepa- 
ration of  opium. 

As  will  be  seen,  each  case  of  headache  requires  special  ti 
inent  and  a  certain  amount  of  experimentation  in  order  to  learn  the 
idiosyncrasy  of  the  patient. 

Migu.uxk,  Skk-Hk  \i>.\<  he,  Eemk  baxia.— Migraine  is  ;. 
stitutimial  neurosis  characterized  by  periodical  attacks  of  pain  chiefly 
in  the  course  of  the  fifth  nerve.     The  pain  is  often  associated  with 
nausea  or  vomiting,  mental  depression,  vasomotor  disturbances  snch 
as  flushing  or  pallor  of  the  face,  by  flashes  of  light,  vertigo,  tinnitus 


182  DISEASES    OF   THE    NERVOUS    SYSTEM. 

auriinn,  and  in  rare  cases  by  partial  paralysis  of  one  oculomotor 
nerve. 

It  will  thus  be  seen  that  migraine  is  more  than  ordinary  head- 
ache and  unlike  an  ordinary  neuralgia. 

Etiology. — The  disease  is  very  common  in  civilized  countries  and 
is  frequent  in  America.  It  occurs  oftenest  in  women  in  the  propor- 
tion of  about  three  to  one,  and  it  begins  in  most  cases  at  or  a  little 
before  the  age  of  puberty.  It  may  begin  as  early  as  the  fifth  or 
even  the  second  year.  It  occurs  in  neurotic  families,  and  there  is 
very  often  a  history  of  direct  inheritance.  Other  neuralgic  trou- 
bles, epileps}*,  and  gout  may  be  found  in  the  family  history.  The 
attacks  occur  oftenest  in  the  winter  in  our  climate.  The  cases  that 
begin  in  childhood  and  early  life  are  sometimes  started  by  overwork 
at  school,  but  usually  no  especial  cause  can  be  found.  When  they 
begin  after  maturity,  a  history  of  excesses  in  work,  injury,  shock, 
or  exhausting  disease  is  found.  Migrainous  patients  usually  have 
some  refractive  disorder  of  the  eye  or  a  weakness  of  eye  muscles, 
and  this  condition  is  one  factor  in  bringing  on  or  keeping  up  the 
headaches.  Autotoxsemia  from  uric  acid  and  poisons  developed  in 
the  intestinal  tract  is  considered  an  important  factor  in  migraine 
by  some. 

Symptoms. — The  patient  for  several  days  may  feel  a  sense  of 
malaise  and  depression ;  usually,  however,  the  prodromal  stage  lasts 
only  a  few  hours  or  a  day.  The  attack  often  comes  on  in  the  morn- 
ing and  gradually  increases  in  intensity  until  the  victim  has  to  give 
up  work  and  lie  down.  Sometimes  the  pain  comes  on  with  almost 
epileptic  suddenness  and  violence,  waking  a  person  from  sleep  or 
compelling  him  at  once  to  lie  down.  Fulgurating  migraine  is  the 
term  applied  to  this  type.  The  pain  starts  in  one  side  of  the  head, 
usually  in  the  forehead,  but  often  in  the  occiput.  It  increases  and 
finally  may  involve  the  whole  head.  The  pain  is  of  a  tense,  throb- 
bing, blinding  character,  increased  by  jars,  light,  and  noises.  It 
is  accompanied  by  dimness  of  vision,  often  by  flashes  of  light  or 
dark  or  light  spots  variously  colored  floating  before  the  eyes.  Re- 
striction of  the  visual  field,  sometimes  in  the  form  of  hemianopsia, 
may  occur.  Vertigo,  tinnitus  aurium,  confusion  of  ideas,  feeling  of 
stupor,  disturbances  of  memory,  are  not  uncommon;  nausea  and 
even  vomiting  are  the  rule.  The  vomited  matter  is  at  first  chiefly 
mucus,  but  it  may  later  become  yellow  and  bitter  from  the  presence  of 
bile.  Hence  the  term  "bilious  headache,"  which  is  an  improper 
one,  because  the  bile  is  only  the  result  of  retrostaltic  action  from 
the  vomiting.  Migraine  is  not  the  result  of  gastric  or  liver  dis- 
order. 

The  patient's  face  usually  is  pale  and  gives  the  evidence  of  acute 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES. 


183 


suffering.  The  flushed  face  is  very  rare;  the  distinction  between 
angiospastic  or  pallid  migraine  and  angioparalytic  or  congestive 
migraine  is  not  of  clinical  value.  The  pulse  is  small  and  hard,  and 
may  be  lessened  in  rapidity.  The  temperature  in  children  often 
rises. 

The  attack  lasts  from  six  to  twelve  or  twenty-four  hours,  occa- 
sionally even  two  or  three  days.     As  the  intensity  of  the  pain  lessens 


Fig.  97—  Scintillating  and  Zig-Zag  lights  seen  in  Migrainous  Attacks (Bablnsfct). 


the  patient  sinks  to  sleep,  and   awakens  next  morning  feeling  re- 
freshed and  better  than  before  the  attack. 

The  attacks  occur  at  varying  periods,  fortnightly  or  monthly, 
and  even  weekly.  In  women  they  often  occur  during  menstruation. 
Some  women  are  entirely  free  from  them  .luring  pregnancy.  At 
about  the  time  of  the  menopause  in  women,  and  at  about  the  same 
time  of  life  in  men,  the  disease  lessens  in  severity  and  as  a  rule  dis- 
appears. Some  form  of  neuralgia  or  some  neurosis  in  rare  cases 
takes  its  place. 


184  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Complicating  Symptoms. — Partial  oculomotor  paralysis,  tem- 
porary aphasia,  slight  hemiplegia,  heminumbness,  peculiar  odors 
or  tastes,  convulsive  movements  of  the  body  almost  resembling 
epileptic  attacks,  occur. 

Cases  presenting  these  symptoms  are  rare.  When  they  occur  in 
one  case,  however,  they  always  occur  in  each  attack  unless  it  is 
modified  by  treatment. 

Vicarious  Attacks. — Migraine  is  sometimes  associated  with  epi- 
lepsy, locomotor  ataxia,  or  insanity ;  that  is  to  say,  persons  in  early 
life  have  had  migraine  and  later  developed  the  diseases  mentioned. 
The  relation  between  these  diseases,  however,  is  not  so  close  as 
some  writers  would  lead  us  to  infer.  The  attack  of  migraine  can 
be  sometimes  replaced  by  an  attack  of  gout,  or  visual  disorders,  or 
other  sensory  symptoms,  or  even  by  an  oculomotor  paralysis. 
Sometimes,  instead  of  a  fully  developed  attack,  the  patient  has  a 
sense  of  mental  depression,  with  confusion  of  ideas.  Cases  have 
been  reported  in  which  acute  mania  took  the  place  of  the  headache. 

Types. — Writers  have  described  the  angioparalytic  and  angio- 
spastic types;  also  the  typical,  subtypical,  and  supratypical ;  and 
finally  the  ordinary  type  and  the  ophthalmic  type.  Practically  we 
find  two  Classes : 

(1)  The  typical,  associated  with  visual  disorders  and  having 
most  of  the  symptom  described  above. 

(2)  The  irregular  or  mixed  type,  in  which  with  many  symptoms 
of  ordinary  migraine  there  is  a  history  of  rheumatic  influences  and 
often  of  anaemia  or  dyspepsia.  These  are  cases  of  a  true  migrain- 
ous affection  complicated  with  some  form  of  symptomatic  head- 
ache, such  as  has  been  already  described.  The  mixed  or  irregular 
migraines  are  important  to  recognize,  for  they  call  for  special 
treatment.  They  occur  almost  altogether  in  women;  the  attacks 
are  often  associated  with  weather  changes  and  may  be  of  a  neu- 
ralgic character.  Many  women  have  their  sick-headaches  and 
their  neuralgic  headaches,  so  called,  and  have  to  distinguish  be- 
tween them.  In  mixed  attacks  the  face  is  usually  also  pale,  the 
eyes  are  not  suffused,  nor  is  there  any  visual  or  aural  disturb- 
ance, as  in  migraine.  Sometimes  the  pain  remains  in  the  occipital 
nerves,  and  I  have  met  with  one  patient  who  localizes  her  pain 
there  entirely,  and  who  always  vomits  during  the  attack. 

Pathology. — The  seat  of  the  disease  is  chiefly  in  the  intracranial 
branches  of  the  fifth  nerve  and  of  the  pneumogastric ;  the  upper 
cervical  nerves,  however,  are  often  involved.  There  are  no  morbid 
anatomical  changes  known.  The  most  plausible  theory  of  the  dis- 
ease is  that  it  is  a  fulgurating  neurosis,  in  which  there  are  periodical 
discharges  of  nerve  force,  or  nerve  storms.     The  seat  of  the  dis- 


SENSORY    NEUROSES   OF    THE    CEREBRO-SI'lN  AL    NERVES.        IS5 

charge  is  perhaps  in  the  cerebral  cortex,  or  possibly  in  tin'  pri- 
mary sensory  centres,  i.e.,  the  root  ganglia  of  the  fifth  and  vagus 
nerves.  The  disease  is  certainly  not  in  the  sympathetic  system,  as 
was  once  taught.  The  presence  of  excess  of  uric  acid  or  of  some 
other  autochthonous  poison  as  a  factor  in  the  disease  may  be  re- 
garded as  probable. 

Diagnosis. — The  diagnosis  is  based  upon  the  hereditary  history, 
the  periodicity  and  seat  of  the  attacks,  the  nausea,  the  complicating 
visual  and  other  sensory  symptoms.  It  should  not  be  forgotten  that 
the  same  patient  may  have  migraine  and  other  neuralgias,  or  may 
have  also  an  organic  brain  or  renal  disease. 

Treatment — Prophylaxis. — Children  of  families  in  which  this 
neurosis  exists  should  be  carefully  watched  during  the  ages  between 
five  and  twenty.  The  eyes  and  nose  should  be  examined.  They 
should  not  be  subjected  to  excessive  mental  or  visual  strain,  and  if 
attacks  develop  they  should  be  promptly  treated.  The  application 
of  glasses  should  be  considered,  but  not  hastily  adopted. 

As  regards  constitutional  treatment,  the  best  measures  for  curing 
a  case  of  migraine  consist  in  correcting  any  visual  or  nasal  defect, 
such  diet  and  exercise  as  secure  tone  to  the  nerves,  and  the  continu- 
ous use  internally  of  bromide  of  potassium,  nitroglycerin,  cannabis 
indica,  or  arsenic.  The  diet  should  be  very  simple  and  non-fermen- 
tative. It  should  be  mainly  of  meats  and  green  vegetables  and 
cooked  fruits.  The  meats  should  be  moderate  in  amount,  and  some- 
times only  fish  and  poultry  should  be  allowed. 

Of  the  drugs,  salicylate  of  sodium  and  cannabis  indica,  either 
with  or  without  arsenic,  are  the  most  trustworthy,  while  the  bromides 
are  the  least.  The  hemp  should  be  given  in  large  doses  and  for  a 
long  time,  gr.  -£  to  gr.  i.,  ter  in  die.  The  salicylates  may  be  com- 
bined with  an  alkaline  laxative  like  Rochelle  salts,  a  dose  being 
taken  night  and  morning.  Much  stress  is  laid  by  some  niton  ocular 
muscular  insufficiencies,  and  I  believe  that  such  conditions  should  be 
remedied,  but  place  little  confidence  in  them  alone.  On  the  other 
hand,  tin-  collection  of  small  or  large  degrees  of  astigmatism  and 
hypermetropia  sometimes  produces  surprisingly  good  results.  The 
reported  cure  of  numerous  cases  of  migraine  by  treatment  of  nasal 
hypertrophies  and  catarrh  should  not  excite  too  much  confidence  in 
such  measures.  In  fact,  since  migraine  is  a  constitutional  neurosis, 
one  cannot  expect  permanent  results  from  removing  reflex  irritants 
alone.  The  daily  use  of  a  Btrong galvanic  current  four  to  eight  mil- 
liamperes  (eight,  to  ten  cells)  for  ten  minutes  is  useful. 

For  the  relief  <>j'  the  attack  the  following  drugs  may  be  given: 
Salicylate  of  sodium,  gr.  xx.  ;  caffeine,  gr.  ij.  to  v.,  with  benzoateof 
sodium,  gr.  x. ;  antipyrin,  gr.  v.  <j.  j  h. ;  phenacetin,  gr.  x.  to  xv. 


186 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


or  more ;  powdered  guarana,  gr.  xx. ;  menthol,  gr.  v.  to  x.  in  hot 
water ;  muriate  of  ammonia,  gr.  xxx.  to  3  i. ;  bromide  of  potas- 
sium, gr.  xx.  Antipyrin  and  phenacetin  are  the  most  certain  of 
the  above  drugs,  but  they  lose  their  effect  after  a  time,  as  do  almost 
all  the  other  drugs,  and  finally  patients  give  up  treatment  or  resort 
to  codeine  or  morphine.  Chloral  and  a  hot  foot  bath  break  up  attacks 
sometimes. 

Locally  galvanic  currents  are  sometimes  helpful,  and  so  are 
static  sparks.  Hot  applications  and  pencilling  with  menthol  give 
relief  to  some.     Quiet  and  rest  are  spontaneously  resorted  to. 


Carotid 


Spheno- 
palatine G 


Neuroses  of  the  Acoustic  Nerve. 

Anatomy. — The  auditory  or  eighth  cranial  nerve  has  two  differ- 
ent parts.  One  por- 
tion passes  to  the 
cochlea  and  utricle  and 
saccules;  it  has  to  do 
with  the  sense  of  hear- 
ing; the  other  goes 
to  the  semicircular 
canals,  and  has  to  do 
with  that  sense  by 
which  we  appreciate 
the  position  of  our 
body  and  its  relations 
to  space.  The  eighth 
nerve  is  thus  an  auditory  and  a 
space-sense  nerve. 

The  auditory  fibres  enter  the 
medulla  by  two  roots,  a  lateral  or 
posterior  and  a  median  or  anterior. 
The  lateral  root  has  mainly 
auditory  fibres.  The  space-sense 
fibres  enter  chiefly  by  the  median 
root.  These  roots  are  connected 
with  three  nuclei,  viz.  :  (1)  The 
chief  nucleus  (dorsal,  central, 
inner  nucleus) ;  (2)  the  large- 
celled  nucleus  (Dei- 
ter's);  and  (3)  the 
accessory  nucleus  (ven- 
tral, anterior,  lateral). 
The  chief  nucleus  (1) 
is  a  large  mass  of  gray 
matter  composed  of  small  nerve  cells  and  lies  superficially  just 
beneath  the  floor  of  the  fourth  ventricle.  The  large-celled  nucleus 
(2)  lies   to  the  outer  side  of  and  below  it.     The  accessory  nucleus 


Fig.  98.— Glosso-Pharyngeal  Nerve  (Young). 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES.       187 

(3)  lies  in  the  substance  of  the  lateral  root,  and  between  it  and 
the  median  root.  The  lateral  root  is  the  one  coming  chiefly  from 
the  cochlea,  and  is,  as  stated,  mainly  a  nerve  of  hearing.  It  is 
connected  most  extensively  with  the  accessory  nucleus,  but  also 
with  the  other  nuclei. 

Through  the  accessory  nucleus  it  connects  by  a  few  fibres  with 
the  superior  olives,  mostly  of  the  opposite  side;  thence  fibres  pass 
up  through  the  lateral  lemniscus,  to  the  posterior  corpora  quadri- 
gemina;  thence  to  the  cortex  of  the  first  and  second  convolutions  of 
the  temporo-sphenoial  lobes.  Other  fibres  pass  up  directly  through 
the  lemniscus  and  the  tegmental  or  sensory  tracts  to  the  cortex  of 
the  temporal  lobes.  Connections  are  numerous,  also,  with  other 
cranial  nerve  nuclei.  The  lateral  root  also  sends  fibres  to  the  chief 
nucleus  and  (via  the  striae  acusticae)  into'  the  raphe,  and  thence  to 
the  formatio  reticularis  and  sensory  tract.  These  fibres  go  also 
to  the  posterior  tubercles  of  the  corpora  quadrigemina  and  thence 
to  the  cortex  of  the  temporal  lobe. 

The  median  root  is  connected  chiefly  with  the  large-cell  nucleus 
(2),  but  also  with  the  chief  nucleus  (1).  From  these  nuclei  fibres 
pass  up  in  the  posterior  cerebellar  peduncle  through  the  direct  sen- 
sory tract  of  the  cerebellum  to  the  roof  nucleus  or  the  emboliform 
and  globose  nuclei. 

The  diseases  of  the  eighth  or  acoustic  and  space-sense  nerve 
which  are  of  special  interest  to  the  neurologist  are  auditory  paralysis 
or  nervous  deafness,  hyperacusis,  tinnitus  aurium,  and  auditory 
vertigo,  or  Meniere's  disease.  These  diseases  correspond  with 
loss,  excess,  and  perversion  or  irritation  of  function. 

Nervous  Deafness   (Acoustic  Pabaxysis). 

Nervous  deafness  may  be  due  to  lesions  (1)  of  the  cortical 
centres  of  hearing,  (2)  of  the  acoustic  nuclei,  and  (3)  of  the  acoustic 
nerve  itself  or  its  end  organ.  Practically  it  is  almost  always  the 
nerve  and  the  internal  ear  which  are  affected. 

Etiology. — 1.  Cortical  nervous  deafness  has  been  known  to  occur 
in  a  few  instances  from  lesions  of  both  temporal  lobes  (Mills).  A 
lesion  in  the  left  temporal  lobe  causes  a  form  of  sensory  aphasia 
called  word  deafness.  A  lesion  in  the  right  temporal  lobe  may 
cause  some  deafness  in  the  left  ear.  The  deafness  of  hysteria  is  of 
cortical  origin. 

2.  Deafness  from  lesion  of  the  acoustic  nucleus  or  nerve  root. 

Cerebro-spinal  meningitis  in  the  young  and  syphilitic  meningitis 
in  the  adult  are  the  more  frequent  causes  of  this  form.  Tumors 
and  hemorrhages  may  also  be  causes.  When  the  auditory  nucleus 
and  nerve  root  are  affected  by  these  diseases,  its  peripheral  termi- 
nations in  the  labyrinth  are  also  often  involved,  so  that  sharp  dis- 


188  DISEASES    OF   THE   NERVOUS    SYSTEM. 

tinctions  cannot  always  be  drawn  beween  this  form  and  that  due  to 
labyrinthine  disease. 

3.  Deafness  from  Labyrinthine  Disease. — The  causes  are  drugs, 
such  as  quinine  and  the  salicylates;  inflammations,  including 
syphilitic  exudates;  injuries;  hemorrhages;  tumors;  primary  atro- 
phy, which  may  occur  in  locomotor  ataxia;  mechanical  causes,  such 
as  the  constant  noises  and  jarring  to  which  locomotive  engineers  and 
boiler  makers  are  subject. 

Symptoms  of  Nervous  Deafness. — The  dominant  symptom  is 
loss  of  hearing,  but  this  may  be  accompanied  by  vertigo,  tinnitus, 
and  even  forced  movements. 

In  hysterical  deafness  the  loss  of  hearing  is  rarely  complete,  is 
unilateral,  and  especially  involves  high  and  low  notes.  Deafness 
from  involvement  of  the  nucleus  and  nerve  root  is  usually  accom- 
panied by  other  symptoms  of  a  basilar  meningitis  or  lesion  of  the 
pons  and  medulla.  Labyrinthine  deafness  is  often  associated  with 
vertigo,  tinnitus,  and  forced  movements,  when  it  may  become  a 
symptom  complex  known  as  "  Meniere's  disease." 

Sudden  total  deafness  is  characteristic  of  syphilitic  disease  of 
the  internal  ear.  In  genuine  nervous  deafness,  unless  the  deafness 
is  absolute,  bone  conduction  is  lost,  while  aerial  conduction  is  pre- 
served. A  tuning-fork  vibrating  on  the  skull  or  mastoid  is  not 
heard  by  the  affected  ear,  though  it  is  heard  when  held  in  the  air 
close  by  this  ear.  Changes  of  reaction  to  the  electrical  current 
occur,  but  the  tests  are  difficult  and  the  results  unsatisfactory. 

The  treatment  depends  upon  the  seat  and  nature  of  the  lesion. 
In  labyrinthine  deafness  it  is  generally  limited  to  the  use  of  iodide 
of  potassium,  mercury,  pilocarpine,  leeches,  and  the  galvanic  cur- 
rent. Local  applications  and  surgical  interference  may  be  required. 
The  treatment  of  nervous  deafness  in  which  vertigo,  forced  move- 
ments, and  tinnitus  are  the  dominant  symptoms  will  be  discussed 
under  these  heads. 

Tinnitus  Aukh-m.    Tinnitus  Cerebri   (NorsEs  ix  the  Ear 
and  Head). 

Subjective  sounds  resembling  hissing,  buzzing,  humming,  beat- 
ing, musical  notes,  etc.,  are  classed  together  under  the  general  head 
of  tinnitus  aurium.     It  is  a  very  common  sjanptom. 

Etiology. — The  disease  attacks  adults  in  middle  and  later  life. 
Men  and  women  are  alike  affected.  Neuropathic  constitutions  and 
an  unstable  circulation  favor  it.  The  arterio-sclerosis  of  old  age, 
cerebral  anaemia  and  congestion,  sunstroke,  tobacco,  and  alcoholism 
lead  to  it.     It  occurs  often  in  melancholia  and  in  neurasthenia. 


SENSORY    NEUROSES   OF   THE    CEREBRO-SPINAL   NERVES.       189 

Some  local  disease  or  congestion  of  the  middle  or  internal  ear  is 
usually  present.  Tinnitus  occurs  in  Bright' s  disease,  gout,  and 
dyspepsia. 

Disease  of  the  auditory  nuclei  and  auditory  tracts  rarely,  if  ever, 
causes  tinnitus;  but  chronic  pachymeningitis,  such  as  follows  blows 
on  the  head,  sunstroke,  alcoholism,  etc.,  may  be  attended  by  most 
annoying  tinnitus,  which  is  often  not  so  much  in  the  ears  as  in  the 
head — a  tinnitus  cerebri.  In  old  people  with  thickened  arteries  and 
imperfect  brain  nutrition  a  similar  condition  may  occur. 

Tinnitus  accompanies  insanity  sometimes,  and  may  be  the  source 
of  aural  hallucinations. 

A  kind  of  tinnitus  may  accompany  migraine  and  take  the  form 
of  an  aura  in  epilepsy. 

Despite  this  long  list  of  causes,  the  chief  factors  may  be  summed 
up  as  neurasthenic  states,  local  ear  disease,  humoral  poisons  and 
irritants,  reflex  irritants,  arterio-sclerosis. 

The  symptoms  are  indicated  by  the  name  of  the  malady.  They 
may  come  on  suddenly,  but  usually  develop  slowly.  Some  deafness 
and  occasional  vertigo  are  often  present.  The  noise  is  located  in 
one  ear,  as  a  rule.  Sometimes  it  is  said  to  be  simply  "  in  the  head." 
The  sounds  are  generally  present  all  the  time,  giving  the  patient 
little  rest  and  making  life  a  burden.  They  vary  greatly  in  char- 
acter and  intensity.  These  variations  are  indicated  in  the  study  of 
the  diagnosis. 

The  Diagnosis. — The  recognition  of  the  symptom  is  easy.  The 
principal  thing  is  to  discover  its  seat  and  cause. 

The  ear  should  of  course  be  examined  for  external  or  middle-ear 
disease. 

If  the  tinnitus  is  pulsating  and  synchronous  with  the  heartbeats 
and  stopped  by  carotid  compression,  it  maybe  inferred  that  it  is 
due  to  vasomotor  paralysis,  or  inflammatory  congestion,  or  aneurism. 

If  the  sound  is  not  in  the  ear,  but  in  the  head,  and  not  asso- 
ciated with  deafness  or  ear  disease,  the  trouble  is  probably  central, 
and  most  likely  is  of  meningeal  or  arteriosclerotic  origin. 

Noises  which  are  complex  or  take  the  form  of  musical  sounds 
or  words  are  probably  central. 

Constant  rushing,  knocking,  pulsating  noises  are  due  to  conges- 
tion, hemorrhage,  or  inflammatory  effusion  in  the  labyrinth. 

Moist  sounds  of  a  gurgling,  bubbling,  boiling,  singing,  whistling, 
shell-like  roaring  character  indicate  of  the  middle  ear.  with 

fluid  exudation  or  catarrh  of  the  Eustachian  tube,  or  irritation  of 
the  external  auditory  canal,  mastoid  cells,  or  postnasal  spa 

Dry    roaring    and    ringing  noises    are    due    to  non-suppurative 


190  DISEASES   OF   THE   NERVOUS   SYSTEM. 

catarrh  of  the  middle  ear,  disease  of  the  muscles  or  nervous  supply 
of  the  tympanum,  meningitis,  tumors,  and  syphilis. 

The  condition  of  the  digestion  should  be  inquired  into  and  the 
existence  of  renal,  arterial,  or  central  nervous  disease  investigated. 

Treatment. — Hydrobromic  acid  and  the  other  bromides,  given  in 
ordinary  doses,  are  the  surest  remedies  for  this  trouble.  They 
may  be  combined  with  digitalis.  Iodide  of  potassium  and  iodide  of 
ethyl  often  are  useful.  Nitroglycerin  is  sometimes  of  value  in 
patients  with  hard  arteries.  A  combination  of  digitalis,  bromide, 
and  nitroglycerin  has  given  me  the  best  results.  Occasionally  tonics 
are  indicated.  I  have  seen  but  little  good  from  electricity  or 
counter-irritation.  Of  course  middle-ear  disease  must  be  treated  if 
it  is  present. 

Vertigo   (Dizziness,   Giddiness). 

Vertigo  is  a  disturbance  of  consciousness  characterized  by  ap- 
parent movements  of  external  objects  or  of  the  person  himself.  If 
external  objects  whirl  around,  the  vertigo  is  called  objective;  if  the 
person  himself  seems  to  move,  it  is  called  subjective.  Vertigo  is 
almost  always  a  symptom.     In  rare  cases  it  appears  to  be  idiopathic. 

Vertigo  is  connected  more  or  less  with  our  space  sensations,  and 
hence  it  will  be  described  here  under  disorders  of  the  eighth  cranial 
nerve  and  its  central  representations. 

Etiology.- — The  causes  of  vertigo  may  be  classed  somewhat  like 
those  of  headache,  as  follows : 

1,  Hsemic,  etc.,  anaemia,  hyperemia,  toxaemia  from  tobacco  and 
alcohol ;  2,  arterio-sclerosis ;  3,  acoustic-nerve  irritation ;  4,  neu- 
roses; epilepsy,  neurasthenia;  5,  reflex:  ocular,  gastric;  organic 
brain  disease;  7,  mechanical  causes  like  electricity,  swinging,  etc. 

Based  mainly  on  the  etiology,  we  have  as  a  practical  classifica- 
tion of  ordinary  cases  of  vertigo :  toxic,  auditory,  gastric  and  bilious, 
ocular,  neurasthenic,  and  epileptic  forms.  The  various  causes  of 
vertigo  act  partly  by  irritating  the  space-sense  nerve  and  thus  dis- 
turbing our  sense  of  relation  to  external  objects,  partly  by  irritating 
the  cortical  centres  of  the  brain. 

Symptoms. — Vertigo  comes  on  suddenly,  and  lasts,  as  a  rule, 
for  but  a  moment.  The  floor  rises  and  sinks,  or  objects  whirl 
around  (objective  vertigo),  or  the  patient  seems  whirling  around  or 
falling.  The  ideas  are  confused;  there  are  a  sense  of  alarm  and  a 
feeling  of  faintness.  The  patient  totters,  sometimes  falls;  there 
may  be  nausea  or  vomiting.  In  some  forms  there  is  momentary  loss 
of  consciousness,  or  syncope.  Vertigo  usually  comes  on  in  short 
attacks,  but  in  toxaemic  states,  as  in  alcoholism  or  nicotinism,  it  is 


SENSORY    NEUROSES    OF   THE   CEREBRO-SPINAL    NERVES.       191 

almost  constant  while  the  poison  is  in  the  system.  Vertigo  may 
become  chronic  or  nearly  so;  and  if  severe  it  forms  what  is  called 
the  status  veHiginosus  (Mitchell).  Vertigo  is  increased  by  rising  or 
sudden  movements  and  lessened  by  lying  down. 

Vertigo  may  be  due  to  organic  lesions  of  the  cerebellum  and  its 
peduncles,  or  of  the  labj'rinth;  it  is  then  associated  with  forced 
movements  of  the  body. 

Symptoms  of  Special  Forms — Auditory  Vertigo  {Meniere' s  Dis- 
ease).—A  large  proportion  of  vertigoes  are  due  to  disease  or  irrita- 
tion of  the  eighth  nerve  and  its  centres.  The  common  cause  is  local 
disease  of  the  labyrinth.  When  this  produces  severe  attacks  of 
vertigo  with  nausea  and  perhaps  syncope,  it  is  called  "  Meniere's 
disease."  The  name  is  often  applied  to  any  form  of  auditory  ver- 
tigo. Meniere's  type  is  always  due  to  organic  disease  of  the  laby- 
rinth. It  is  accompanied  by  progressive  deafness,  and  sometimes 
by  tinnitus  and  forced  movements,  or  even  an  utter  inability  to 
walk  steadily.  When  the  deafness  is  complete  the  vertigo  ceases, 
because  the  nerve  end  organ  is  destroyed.  Mild  forms  of  auditory 
vertigo  present  nothing  unusual  except  those  due  to  involvement  of 
the  nerve  of  hearing. 

Many  forms  of  vertigo,  such  as  the  gastric  and  toxic,  occur 
through  a  reflex  disturbance  of  the  eighth  nerve.  The  auditory 
nuclei  are  connected  with  those  of  the  vagi.  The  labyrinth  is  sup- 
plied with  blood  by  the  vertebral  artery,  whose  calibre  is  controlled 
by  sympathetic  fibres  which  are  in  close  connection  with  fibres  to 
the  stomach.  Hence  reflex  effects  may  occur  through  contiguity  of 
the  central  nuclei  and  by  reflex  spasm  of  the  vessels  of  the  internal 
ear.  "  Stomachal  vertigo"  is  the  name  given  to  a  very  severe  form 
of  reflex  vertigo.  It  occurs  generally  in  persons  whose  stomachs 
are  overloaded  and  whose  digestion  is  paralyzed  by  its  load.  It  is 
accompanied  by  loss  of  consciousness. 

Bilious  and  Lithcemic  Vertigo. — In  conditions  of  dyspepsia, 
constipation,  and  hepatic  torpor,  the  disordered  stomach  and  bowel 
suddenly  discharge  into  the  blood  irritant  substances  which  pass  to 
the  brain  and  by  direct  action  on  the  nervous  centres  cause  vertigo. 
This  is  probably  the  explanation  of  the  vertigo  of  biliousness  and 
constipation.  It  is  a  paroxysmal  vertigo,  noted  most  in  the  morn- 
ing, not  very  severe,  and  often  accompanied  by  nausea. 

Neurotic  Vertigo. — The  symptoms  of  epileptic  vertigo  will  be 
described  under  that  head. 

Neurasthenic  vertigo  is  a  not  uncommon  symptom.  The  attacks 
are  short,  generally  subjective,  not  severe  or  accompanied  by  nausea 
or  syncope,  but  they  often  cause  much  alarm.      Underlying  them  are 


192  DISEASES    OF   THE    NERVOUS   SYSTEM. 

exhausted  and  irritable  nerve  centres,  with  ocular,  gastric,  and  hu- 
moral irritations. 

A  neurotic  vertigo  occurs  sometimes  in  the  form  of  attacks 
almost  exactly  resembling  seasickness.  There  are  intense  vertigo, 
nausea,  and  faintness  lasting  for  hours,  coming  ou  suddenly  without 
known  cause  except  overwork  or  excitement.  The  attacks  occur  in 
neurotic  subjects  and  are  analogous  to  other  nervous  crises.  It  is 
a  periodical  neurosis  of  the  space-sense  nerve. 

A  form  of  vertigo  which  is  psychical  in  character  occurs  in  -neur- 
asthenics. It  consists  in  a  sudden  sensation  of  insecurity,  an  ap- 
prehension of  falling,  of  an  approaching  loss  of  consciousness. 
There  is  no  true  vertigo,  either  subjective  or  objective,  and  the 
patients  really  never  stagger  or  fall.  It  is  a  psychosis  rather  than 
a  nervous  condition. 

In  some  nervous  subjects  there  occurs  a  sudden  giving  way  of 
the  legs.  There  is  no  conscious  vertigo,  yet  such  probably  exists. 
The  symptom  is  noted  in  exophthalmic  goitre.  It  is  a  "  stumbling 
vertigo. " 

Ocular  Vertigo  is  a  rare  symptom,  but  is,  when  present,  chronic 
and  annoying.  It  is  caused  by  refractive  errors  and  unequal  action 
of  the  ocular  muscles. 

The  mechanical  vertigoes  such  as  seasickness,  car  sickness,  etc., 
are  produced  by  swinging,  or  whirling,  the  movements  of  the  ship, 
steam  car,  and  elevators.  Iiailway  mail  clerks,  elevator  boys,  often 
suffer  from  chronic  disturbances  of  a  vertiginous  character.  Ocular 
and  auditory  nerve  sensations  enter  mainly  into  the  causation  of  the 
troubles. 

Arteriosclerotic  Vertigo,  Senile  Vertigo. — This  occurs  in  persons 
who  have  arteriosclerotic  changes  in  the  brain  vessels,  either  from 
disease  or  senility.  The  symptom  is  caused  by  impaired  brain  nu- 
trition with  consequent  anaemia.  Senile  vertigo  may  also  be  due 
to  a  weak  and  fatty  heart. 

Pathology. — The  consciousness  of  the  proper  equilibrium  of  the 
body  and  of  its  relations  to  the  external  world  depends  upon  the  con- 
tinuous inflow  of  nervous  impulses  from  the  eye  and  its  muscles, 
from  the  nerves  of  the  muscles,  joints,  and  viscera,  and  from 
the  ear.  Anything  which  suddenly  disorders  this  even  inflow 
may  ca\ise  a  disturbance  of  consciousness  and  sensations  of 
vertigo. 

The  aural  impulses  come  from  the  semicircular  canals  and 
ampulke;  they  are  the  most  important.  These  impulses  are  not 
felt  in  consciousness  normally,  but  go  to  certain  lower  centres  chiefly 
in  the  vermis  of  the  cerebellum.  "From  this  point  they  influence  the 
acts  concerned  in  holding  the  body  in  equilibrium. 


SENSOKY    NEUROSES    OF   THE    CEREBRO-SPINAL    NERVES.       193 

When  impulses  from  the  eye  and  its  adjusting  mechanism  do  not 
flow  in  normally,  there  may  be  disturbance  of  consciousness  and  a 
feeling  of  vertigo.  Probably  visceral  impulses  can  produce  a  similar 
disturbance.  Everything  which  suddenly  interferes  with  the  nutri- 
tion of  the  cortex  of  the  brain,  such  as  anaemia  and  poisons,  may 
lead  to  giddiness  by  lowering  the  level  of  consciousness  and  confus- 
ing the  sensory  inflow. 

Did  gnosis. — In  investigating  vertigo  the  physician  should  find 
(1)  whether  it  is  subjective  or  objective,  (2)  paroxysmal  or  chronic, 
(3)  accompanied  by  ear  symptom,  nausea,  tinnitus,  and  loss  of 
consciousness.  He  should  then  direct  himself  to  finding  the  special 
cause  and  seat,  remembering  that  the  auditory,  gastric,  toxic,  and 
neurasthenic  are  the  common  forms.  In  elderly  persons  the  arteries 
should  be  carefully  examined.  In  young  persons  the  possibility  of 
epilepsy  must  be  remembered. 

The  prognosis  depends  upon  the  cause.  Epileptic  vertigo  and 
vertigo  from  organic  disease  are  most  serious.  Labyrinthine  ver- 
tigo usually  ceases  when  complete  deafness  occurs.  The  other 
forms  of  vertigo  are  usually  susceptible  of  relief. 

Treatment. — The  attack  is  treated  by  rest  in  the  horizontal 
position  and  the  administration  of  a  volatile  stimulant.  The  dis- 
order must  then  be  treated  in  accordance  with  the  cause. 

In  Meniere's  vertigo  the  use  of  quinine  by  Charcot's  method  is 
said  to  be  useful.  Quinine  is  given  in  doses  which  are  gradually 
increased  until  cinchonism  results;  then  the  drug  is  stopped. 
Mitchell  advises  the  addition  of  hydrobromic  acid;  Gowers  advises 
the  use  of  salicylate  of  sodium  in  five-grain  doses  instead  of  quinine. 
Hirt  recommends  ten  drops  of  a  two-per-cent  solution  of  pilocarpine 
injected  hypodermieaily  every  other  day. 

Neurasthenic  vertigo  is  cured  by  rest  and  attention  to  diet,  laxa- 
tives and  mineral  acids  being  used.  Hydrobromic  acid  with  pepsin 
and  glycerin  are  often  very  helpful  here.  Gastric  vertigo  is  to  be 
treated  with  saline  laxatives  and  simple  bitters  before  meals. 

In  the  vertigo  of  "  biliousness"  and  litha-mia  there  is  often  a 
neurasthenic  element,  and  a  similar  attention  to  diet  and  to  the 
digestive  organs  is  indicated.  In  arterio-sclerotic  and  senile  vertigo 
small  doses  of  nitroglycerin  and  iodide  of  potassium,  with  or  with- 
out digitalis,  should  be  given.  Rest  and  warmth  of  the  extremities 
are  indicated.  In  all  forms  of  vertigo  bromide  of  potassium  is  help- 
ful and  will  relieve  the  symptoms  for  a  time.  It  is  the  best  symp- 
tomatic remedy.  Counter-irritation  to  the  neck  or  mastoid  region 
by  the  cautery  does  good  occasionally. 
13 


194  DISEASES   OF   THE    NERVOUS   SI  STEM. 

There  are  two  peculiar  forms  of  disease  to  which  the  name 
vertigo  has  been  attached  which  may  be  described  here. 

Laryngeal  Syncope  (Laryngeal  Vertigo,  L.  Epilepsy). — 
This  is  a  rare  form  of  disorder  characterized  by  attacks  of  pares- 
thesia of  the  throat,  with  coughing,  followed  by  sudden  syncope, 
and  sometimes  by  slight  convulsive  movements. 

The  disease  occurs  chiefly  in  males  at  about  the  age  of  fifty, 
though  the  range  of  age  is  from  thirty-five  to  seventy.  Neurotic 
constitution  is  often  present.  There  may  be  a  histoiy  of  injury  and 
the  use  of  stimulants.  Laryngitis,  bronchitis,  apical  phthisis,  and 
asthma  may  be  present. 

At  the  onset  of  the  attacks  a  burning  or  tickling  sensation  is 
felt  in  the  larynx  or  trachea;  there  is  a  spasmodic  cough,  perhaps 
some  asthmatic  or  dyspnceic  symptoms,  when  the  patient  suddenly 
falls  unconscious  for  a  short  time.  The  attacks  may  occur  daily  or 
only  once  in  a  few  weeks.  Most  cases  are  curable,  yet  the  disease 
is  not  without  danger. 

It  is  probably  a  reflex  neurosis,  not  a  true  epilepsy. 

The  treatment  should  be  directed  to  relieving  any  local  con- 
dition or  pulmonary  trouble.  Bromide  of  potassium  should  also  be 
given. 

Paralyzing  Vertigo  (Gerlier's  Disease). — This  is  a  disease 
occurring  only  on  the  farms  in  southern  France  and  Switzerland. 

The  symptoms  consist  of  sudden  attacks  of  ptosis,  vertigo, 
paresis  of  arms  and  legs,  and  cervico-occipital  pain.  The  disease 
is  most  prevalent  in  the  summertime.  It  attacks  chiefly  males. 
Single  attacks  last  not  over  ten  minutes,  but  may  occur  frequently. 

The  cause  is  supposed  to  be  a  special  microbe  developed  in  the 
stables  during  the  heat  of  summer. 

We  are  not  aware  of  its  occurrence  in  America,  though  Seguin 
calls  attention  to  the  close  similarity  of  the  symptoms  to  those  of 
poisoning  by  conium  maculatum. 

Hyperacusis  (Auditory  Hyperesthesia). — When  there  is 
undue  keenness  of  the  sense  of  hearing,  the  condition  is  called 
hyperacusis.  It  occurs  in  hysteria  and  hypnotic  states.  Some 
persons  have  naturally  an  extraordinary  keenness  of  hearing.  In 
facial  paralysis  there  is  sometimes  hyperacusis  due  to  paralysis  of 
the  stapedius. 

When  ordinary  sounds  cause  painful  feelings,  the  condition  is 
called  dysacusis.  This  occurs  in  the  neurasthenic  and  hysterical, 
in  persons  of  enfeebled  vitality,  in  the  brain  congestion  of  fevers, 
and  in  meningitis;  also  in  local  ear  troubles  of  an  inflammatory 
character. 

Sensory  Neuroses  of  the  Glosso-Pharyngeal  Nerve. 

The  anatomy  of  this  mixed  nerve  is  described  under  the  head  of 
motor  neuroses.  The  sensory  fibres  may  be  affected  in  hysteria, 
causing  the  symptom  called  globus,  and  also  the  pharyngeal  anaes- 
thesia found  in  the  same  disease. 


SENSORY   NEUROSES   OF   THE   CEREBRO-SPINAL  NERVES.       195 

The  special  fibres  of  taste  may  be  affected,  causing  ageusia  or 
loss  of  taste. 

Ageusia  (loss  of  the  sense  of  taste)  is  an  affection  in  which 
the  power  to  discriminate  the  tastes  of  bitter,  sweet,  salt,  acid,  and 
alkaline  substances  is  lost. 

Etiology.— It  occurs  oftenest  in  an  incomplete  form  in  facial 
palsy  and  in  hysteria.  Injuries  of  the  trigeminus  and  glosso- 
pharyngeal nerves,  catarrhal  diseases  of  the  mucous  membrane  of 
the  mouth  and  nose,  are  frequent  causes.  It  is  not  caused  by 
cortical  brain  disease  so  far  as  known. 

Some  ageusia  is  present  in  the  imbecile,  and  the  sense  of  taste 
is  less  keen  in  the  lowly  organized  and  criminal  classes. 

Symptoms.—  The  symptoms  are  subjective  and  may  not  be  noticed 
at  first  by  the  patient.  In  hemiageusia  from  facial  palsy  and  hys- 
teria it  has  to  be  looked  for,  as  the  patient  does  not  complain.  The 
tests  are  made  with  solutions  of  salt,  sugar,  vinegar,  and  quinine. 
A  single  solution  of  sugar  usually  answers.  But  the  different  parts  of 
the  tongue  differ  in  sensibility  to  different  substances  (see  Fig.  07). 
Care  must  be  taken  to  exclude  the  nose  as  a  factor  in  taste. 

Pathology. — Ageusia  occurs  as  the  result  of  disease  of  the  roots 
of  the  trigeminus,  especially  of  the  second,  or,  as  Krause  claims, 
the  third;  also  from  disease  of  the  facial  when  the  chorda  tympani 
is  implicated  and  from  disease  of  the  glosso-pharyngeal  root. 

Disease  of  the  trigeminus  and  facial  usually  causes  ageusia  on 
the  anterior  two-thirds  of  the  tongue,  with  loss  of  taste,  especially 
for  sour  and  bitter  substances.  Sometimes,  however,  disease  of  the 
trigeminus  or  disease  of  the  tympanum  involving  the  tympanic 
plexus  and  chorda  tympani  causes  ageusia  of  the  whole  tongue  on 
the  affected  side. 

Ageusia  from  disease  of  the  glosso-pharynge;il  alone  is  very 
rare,  and  then  causes  loss  of  taste  on  the  posterior  third  of  the 
tongue,  soft  palate,  and  pillars  of  the  fauces,  with  loss  of  taste  to 
sweets  and  acids.  A  few  cases  have  been  reported  in  which  paraly- 
sis of  the  glosso-pharyngeal  caused  complete  ageusia  on  the  affected 
side.  It  must  be  inferred,  therefore,  that  taste  fibres  run  some- 
times wholly  in  the  fifth,  more  rarely  wholly  in  the  ninth  nerves, 
and  usually  in  both. 

The  treatment  depends  on  the  cause.  Locally,  cleansing  and 
stimulating  mouth  washes  and  electricity  may  be  used. 

Parageusia,  or  perversions  and  imperfections  in  the  taste  sense, 
are  very  frequent.  They  are  generally  due  to  irritation  of  the  taste 
mi\  es  from  catarrhal  inflammation  of  the  stomach  or  mouth.  They 
also  occur  in  hysteria. 


196  DISEASES    OF    THE    NERVOUS    SYSTEM. 


Sensory  Neuroses  of  the  Upper  Cervical  Nerves. 

The  anatomy  of  these  nerves  has  been  described  under  the  motor 
neuroses.  The  sensory  distribution  to  the  skin  is  shown  in  the 
accompanying  figure  (Fig.  98)-. 

Cervico-Occipital  Neuralgia  —  Neck  Paixs  —  Etiology. — 
Pains  in  the  back  of  the  head  and  neck  occur  in  migraine,  in  hys- 
teria, spinal  irritation,  and  neurasthenia,  as  a  result  of  eye  strain, 
as  a  true  neuralgia,  and  as  a  symptom  of  brain  tumor,  meningitis, 
and  rheumatic  inflammation  of  the  neck  muscles  and  nerves.  True 
cervico-occipital  neuralgia  is  not  rare,  is  much  more  common  in 
women,  occurs  between  the  ages  of  twenty  and  thirty-five,  and  is 
often  a  reflex  of  pelvic  disease. 

Symptoms.  —Migrainous  pains  are  described  elsewhere.  In  spinal 
irritation  and  hysteria  the  trouble  is  central,  or  perhaps  shifting ;  it 
is  especially  characterized  by  a  sharp  boring  pain  just  below  the 
occiput.  With  it  there  may  be  evidences  of  cerebral  congestion  or 
anaemia,  with  vertigo  and  faintness,  but  not  vomiting.  The  boring 
pain  is  almost  pathognomonic  of  spinal  irritation.  In  neurasthenia 
the  pain  is  more  of  a  tired,  aching  character.  In  typical  neuralgia 
the  pain  is  usually  unilateral,  paroxysmal,  and  sharp,  sometimes 
reaching  the  intensity  of  a  tic  douloureux.  There  are  tender  points 
over  the  exit  of  the  nerves.  The  disease  lasts  for  five  or  six  weeks. 
If  of  refiex  origin,  it  may  become  chronic.  The  pains  may  alter- 
nate with  or  take  the  place  of  a  trigeminal  neuralgia.  The  nerves 
involved  are  the  great  and  small  occipital  from  the  second  pair  and 
a  branch  from  the  third  pair. 

Treatment. — General  constitutional  treatment  consists  in  the  use 
of  antirheumatics,  such  as  the  salicylates.  The  muriate  of  am- 
monia has  done  me  good  service.  In  women  pelvic  troubles  should 
be  looked  for ;  in  both  sexes  the  eyes  must  be  attended  to.  Locally, 
counter-irritants,  cupping,  and  leeching  are  useful;  mustard  and 
capsicum  pastes  are  often  a  great  relief.  The  ice  bag  also  is  of  ser- 
vice. Trephining  the  occipital  bone  has  cured  one  obstinate  case, 
and  resecting  the  occipital  nerves  another. 

Sensory   Neuroses    of    the    Lower   Cervical    and    Brachial 

Nerves. 

Cervico-Brachial  Neuralgia. — The  cutaneous  distribution 
of  the  sensory  nerves  of  the  arm  is  shown  in  Figs.  81  and  98. 
Cervico-brachial  neuralgia  is  relatively  rare;  it   occurs  oftener  in 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL    NERVES.       197 

women  and  in  early  adult  and  middle  life.  The  ordinary  causes  of 
neuralgia  produce  it,  but  rheumatism  and  gout  are  rather  promi- 
nent factors.  Overuse  of  the  arm,  in  ameinic  neurasthenic  per- 
sons, is  a  most  potent  cause.  Keflex  irritation  from  carious  teeth 
and  uterine  disease  have  been  found  to  be  causes.  It  occurs  symp- 
toniatically  in  locomotor  ataxia  and  other  cord  diseases.  A  low 
grade  of  neuritis  probably  often  exits. 

Symptoms. — It  begins  somewhat  gradually  with  aching  pains  in 
the  neck,  shoulder,  axilla,  and  along  the  course  of  the  nerves.  The 
pains  gradually  increase  and  are  usually  worse  at  night.  The  pain 
is  increased  by  use  of  the  arm  and  by  exposure.  Only  one  arm  is 
affected.  Painful  points  may  be  felt  in  the  axilla,  at  the  lower  end 
of  the  scapula,  over  the  deltoid,  over  the  ulnar  near  the  wrist,  over 
the  lower  part  of  the  radial  and  sometimes  on  each  side  of  the  lower 
cervical  vertebrae.  There  are  usually  paresthesias  and  numb  feel- 
ings. If  there  is  a  complicating  neuritis,  burning  sensation^  are 
felt  ("causalgia").  There  maybe  anaesthesia,  vasomotor  disturb- 
ances, herpes,  and  muscular  weakness  and  atrophy.  Brachial  neu- 
ralgia generally  involves  all  the  nerves  of  the  plexus.  If  special 
nerves  are  involved  the  ulnar  is  oftenest  affected,  next  the  musculo- 
spiral,  and  last  the  median. 

Digital  neuralgia  sometimes  occurs.  The  pain  is  often  located 
in  a  single  finger.  The  cause  is  usually  a  local  injury  or  neuritis. 
Sometimes  it  is  a  reflex  pain  due  to  some  remote  trouble.  In  a  few 
cases  this  remote  trouble  is  uterine. 

Diagnosis. — The  etiological  diagnosis  is  most  important.  In- 
quiries as  to  a  rheumatic  or  gouty  element  should  be  made.  The 
presence  of  any  serious  amount  of  neuritis  would  be  shown  by  local 
tenderness  and  motor  weakness.  Organic  cord  disease  must  be 
excluded. 

The  prognosis,  if  the  neuralgia  is  funotkmal,  is  good.  If  a  neu- 
ritis  complicates  it,  it  is  more  serious.  If  the  neuritis,  however,  is 
slight  and  is  secondary  to  a  trauma,  or  is  rheumatic  or  gouty,  the 
prognosis  is  favorable.     Ordinary  attacks  last  about  six  weeks. 

The  Treatment. — Salicylate  of  potassium,  iodide  of  potassium, 
or  muriate  of  ammonia  should  be  given  and  in  large  doses.  A.Conitia 
andgelsemiumarenot  of  much  value.      The  electrical  current,  either 

faradic  or  galvanic,  lias  a  very  decided   effect  for  g 1.      Leeching 

helps  some  cases.  Blisters  may  lie  used  in  neuritic  cases.  The 
analgesic  drugs  like  phenacetin  and  antipyrin  and  antifebriu  are 
useful  symptomatica!!}-.     Hot  local  applications  i  me  re- 

lief. Colchicum  cures  some  eases  "I  gouty  origin.  The  most  im- 
portant thing  of  all,  however,  is  to  secure  rest  for  the  arm  ami  also 


198  DISEASES    OF   THE    NERVOUS   SYSTEM. 

for  the  patient.     Putting  the  patient  to  bed  is  the  best  medicine ; 
and  often  the  arm  needs  to  be  put  in  a  splint  or  sling. 

The  Sensory  Neuroses  of  the  Intercostal  Nerves. 

These  are  chiefly  intercostal  neuralgia,  symptomatic  side  pains, 
herpes  zoster.  Paralyses  and  anaesthesias  occur  in  connection  with 
vertebral  and  spinal-cord  diseases. 

Intercostal,  Neuralgia;  Side  Pains — Etiology. — This  is  a 
very  common  neuralgia.  It  occurs  much  oftener  in  women  (partly 
from  corset  pressure)  than  in  men  (seven  to  one).  The  favorite  age 
is  twenty  to  thirty-five;  the  season,  winter.  Anaemia,  neurasthenic 
and  hysterical  conditions,  child  bearing,  pelvic  disorder,  dyspepsia, 
heart  disease,  malaria,  and  lead  poisoning  are  frequent  causes. 
Exposure  and  muscular  strain  are  rare  exciting  causes. 

Symptoms. — The  disease  comes  on  suddenly.  The  pain  in 
typical  cases  is  sharp  and  stabbing,  but  not  much  increased  by 
respiratory  movements.  There  are  tender  points  at  the  seat  of  pain, 
which  is  usually  greatest  over  the  side  at  the  exit  of  the  lateral 
nerve  branches.  Often  a  tender  point  is  felt  over  the  exit  of  the 
dorsal  or  of  the  anterior  branch.  It  is  rare  to  find  all  three  points. 
The  disease  runs  about  the  course  of  facial  neuralgias,  i.e.,  of  two 
to  six  weeks,  but  it  is  sometimes  very  obstinate,  lasting  for  many 
months.  The  sixth  to  tenth  nerves  are  those  oftenest  involved. 
The  left  side  is  more  susceptible  than  the  right  (three  to  one). 

Pathology. — In  most  cases  the  nerve  is  irritated  by  poor  or 
poisoned  blood.  In  a  minority  of  cases  the  pain  is  reflex  from 
stomach,  pelvis,  or  heart.     Sometimes  there  is  a  neuritis. 

Diagnosis. — Probably  one-half  the  pains  in  the  side  are  myalgic 
in  nature,  and  should  be  classed  as  pleurodynia.  These  pains  can  be 
distinguished  by  the  history  of  their  origin  and  of  rheumatic  influ- 
ences, by  their  diffuseness  and  dulness,  by  the  great  tenderness  on 
pressure,  and  the  pain  produced  on  taking  a  deep  breath.  There  is 
another  considerable  proportion  of  cases  in  which  the  pains  are 
mainly  neuralgic,  but  yet  there  are  some  evidences  of  muscular 
complications.      Some  of  these  pains  are  reflex. 

In  the  third  class  of  cases  there  is  the  pure  stabbing  neuralgia. 
The  diagnosis  is  based  on  the  exclusion  of  pleurisy,  rheumatic  and 
reflex  causes,  by  the  character  of  the  pain,  and  the  presence  of 
tender  points. 

Prognosis. — The  prognosis  is  good,  except  for  a  few  chronic 
cases  due  probably  to  a  degenerative  neuritis.  In  some  of  these 
cases  there  is  lead  poisoning. 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES.       199 

Treatment. — The  most  efficacious  treatment  is  a  blister  and  fer- 
ruginous tonics  with  quinine.  In  all  cases  the  heart,  pleura, 
stomach,  and  pelvic  organs  must  be  examined,  and  any  disorder 
relieved.  Iodide  of  potassium  and  ehlorodyne  have  cured  some 
very  bad  cases  in  my  experience.  If  there  is  a  rheumatic  and  mus- 
cular element,  give  salicylates  or  the  analgesics,  apply  heat,  and 
secure  rest  by  adhesive  straps. 

Mammary  neuralgia  (mastodynia)  is  a  form  of  intercostal 
neuralgia  involving  the  anterior  and  lateral  branches  of  the  three  or 
four  upper  dorsal  nerves. 

Etiology. — It  is  caused  by  local  tumors,  or  it  may  be  an  essential 
neuralgia.  The  causes  in  the  latter  class  are  ansemia,  pendent 
breasts,  pressure  from  badly  fitting  corsets,  and  injury. 

Mammary  neuralgia  also  occurs  in  hysterical  women  and  young 
girls  sexually  precocious;  it  may  occur  in  pregnancy  and  during  lac- 
tation. Many  mammary  pains  are  due  simply  to  local  disorder  of 
the  gland.  , 

Symptoms. — Mammary  neuralgia  is  unilateral,  often  very  severe, 
and  if  it  occurs  in  middle  life  is  liable  to  cause  much  mental  depres- 
sion from  fear  of  cancer. 

The  treatment  depends  upon  the  cause.  It  requires  general 
tonic  measures  and  attention  to  the  proper  support  and  protection 
of  the  gland. 

Herpes  Zoster,  Debmatitic  Neuritis  (Shingles). — Almost 
the  only  recognized  form  of  neuritis  of  the  intercostal  nerves  is 
known  under  the  name  of  herpes  zoster.  This  is  an  acute  derma- 
titis, secondary  to  the  neuritis. 

Etiology. — Its  predisposing  causes  are  wounds,  the  morphine 
habit,  rheumatic,  gouty,  and  syphilitic  poisons,  and  emotional  in- 
fluences. The  active  cause  is  in  all  cases  an  infection,  and  the  dis- 
ease sometimes  is  almost  epidemic.  The  inflammation  affects  not 
only  the  nerves  but  flic  spinal  ganglia,  and  especially  the  latter, 
BO  that  the  condition  might  be  called  a  posterior  poliomyelitis 
(Head). 

Symptoms. — It  begins  gradually  with  the  development  of  pain 
and  a  herpetic  eruption  upoii  one  side  of  the  trunk.  It  generally 
involves  the  lower  dorsal  nerves.  The  eruption  follows  the  course 
of  the  nerve,  rarely  extending  to  the  opposite  side.  The  pain  grad- 
ually subsides,  and  the  disease  itself  runs  its  course  in  a  few  weeks. 

Treatment. —  In  tic  early  stage  the  galvanic  current  is  efficacious. 
Local  anodynes  and  protective  ointments  may  be  applied.  Anti- 
rheumatics and  analgesics  are  to  be  administered  internally. 


200  DISEASES    OF   THE   NERVOUS    SYSTEM. 

Sensory  Neuroses  of  the  Lumbar  Nerves. 

The  upper  two  lumbar  nerves  are  almost  entirely  sensory. 
Neuralgias  of  these  nerves  are  called  lum bo-abdominal. 

They  occur  oftener  in  women  and  usually  after  the  thirtieth 
year.  To  the  ordinary  causes  of  neuralgia  Ave  add  straining,  con- 
stipation, and  pelvic  disease.  True  essential  neuralgia  is  rare;  but 
myalgic  and  reflex  pains  from  uterine  disease  are  very  common. 

Symptoms. — There  is  pain  in  the  loins,  back,  and  buttocks,  ex- 
tending down  to  the  hypogastrium  or  genitals  on  one  side.  The 
pain  in  the  back,  however,  is  often  bilateral.  Painfid  points  may 
be  found  after  a  time,  as  in  intercostal  neuralgia.  Sometimes  the 
pain  is  located  in  the  side  of  the  penis  (penile  neuralgia).  Neural- 
gia of  the  long  lumbar  branches  is  called  femoral  or  crural.  A 
common  form  of  this  constitutes  what  is  called  painful  thigh. 
When  these  nerves  are  subject  to  a  lesser  irritation,  causing  sensa- 
tions of  numbness  and  pricking  along  the  thigh,  the  condition  is 
called  meralgia.  In  true  neuralgia,  the  patient  complains  of  pain 
in  the  front  of  the  knee  and  the  anterior  and  outer  parts  of  the 
thigh,  but  has  no  pain  posteriorly  and  none  below  the  knee.  The 
internal  branches  of  the  anterior  crural  nerve  do  not  seem  to  be 
affected,  while  the  middle  and  external  cutaneous  branches  and  the 
genito-crural  nerve  are  involved. 

Disease  of  the  hip  or  of  the  sacro-iliac  joint  or  vertebras  may 
cause  a  reflex  pain  in  the  obturator  nerve,  localized  especially  in  the 
knee  and  back  of  this  joint.  The  fcetal  head  sometimes  compresses 
these  branches,  causing  a  symptomatic  neuralgia.  Diseases  of  the 
internal  genital  organs  are  especially  liable  to  cause  reflex  pain  in 
the  lumbar  nerves.  Diseases  of  the  external  genitals  and  bladder 
more  often  reflect  pains  upon  the  sacral  nerves.  In  biliary  colic 
pains  are  felt  in  the  ilio-inguinal  and  hypogastric  nerves.  Local 
disease  of  the  psoas  muscle  or  iliacus,  in  the  neighborhood  of  Pou- 
part's  ligament,  causes  pains  in  the  lunibar  nerves.  Lumbar  neu- 
ralgias generally  run  a  favorable  and  not  very  long  course. 

Diagnosis. — Lumbar  neuralgia  is  distinguished  from  lumbago 
by  the  unilateral  position,  the  distribution  and  paroxysmal  charac- 
ter of  the  pain,  and  the  lack  of  severe  suffering  on  motion  and  press- 
ure ;  the  tender  points  and  the  absence  of  any  organic  disease. 
Lumbago  comes  on  suddenly,  with  a  history  of  exposure,  is  bilateral 
and  confined  to  a  single  group  of  muscles,  which  are  tender  on  deep 
pressure.  In  lumbar  sprain  the  onset  is  also  sudden,  with  a  history 
of  injury,  great  local  tenderness,  and  evidences  of  trauma. 

The  treatment  is  the  same  as  that  for  neuralgia  in  general.     The 


SENSORY    NEUROSES   OF   THE    CEREBRO-SPINAL    NERVES.       201 

frequent  presence  of  pelvic  disease  and  of  anaemia  and  a  rheumatic 
history  must  be  borne  in  mind. 

Sciatica  (Neuralgia  of  the  Sciatic  Nerve,  Sciatic  Neu- 
ritis).— This  is  a  form  of  neuralgia  occurring  in  middle  life  and 
characterized  by  intense  pain  in  the  course  of  the  sciatic  nerve.  A 
large  proportion  of  the  cases  is  due  to  a  neuritis. 

Etwlogy. — The  disease  occurs  three  times  as  often  in  men  as  in 
women,  and  is  the  only  neuralgia  of  which  this  can  be  said.  Most 
cases  in  this  country  occur  between  the  ages  of  forty  and  fifty ; 
next  between  thirty  and  forty.* 

The  gouty  and  arthritic  diathesis,  and  occupations  which  lead  to 
exposure  and  strain,  predispose  to  the  disease.  It  is  not  rare, 
therefore,  among  laboring  men.  In  younger  persons  a  neurotic 
constitution  predisposes  to  the  disease,  and  in  this  class  the  trouble  is 
more  truly  of  a  neuralgic  character  and  less  of  a  neuritis. 

Most  cases  occur  in  the  autumn  and  winter.  The  exciting  causes 
are  constipation,  pressure  from  hard  seats,  exposure,  muscular 
strain  from  heavy  work,  and  pelvic  disorders.  Symptomatic  sciatica 
may  be  caused  by  the  pressure  of  pelvic  tumors,  injury  to  the 
nerves,  inflammation,  vertebral  and  spinal  disease;  sciatica  occurs 
in  diabetes  and  in  phthisis.  In  elderly  persons  of  a  rheumatic  con- 
stitution inflammatory  processes  about  the  hip-joint  complicate  or 
cause  the  neuralgia. 

Symptoms. — The  disease  begins  rather  suddenly.  Pain  is  felt 
in  the  back  of  the  thigh,  running  down  the  leg  in  the  course  of  the 
nerve.  Generally  it  is  most  marked  in  the  thigh,  extending  up 
often  into  the  lumbar  region.  Sometimes  the  disease  begins  like  a 
lumbago;  more  rarely  pain  is  first  felt  in  the  calf  or  foot.  The  pain 
is  increased  by  motion,  and  the  patient  holds  himself  in  a  con- 
strained position.  The  pelvis  is  tilted  up  toward  the  sound  side  and 
the  trunk  inclined  over  to  the  diseased  side.  After  a  time  this  leads 
in  some  cases  to  a  characteristic  deformity  (sciatic,  scoliosis)  in 
which  the  convexity  of  the  curve  of  the  vertebral  spines  is  directed 
toward  the  diseased  side.  The  pain  is  almost  continuous,  with 
paroxysms  of  great  severity,  which  often  occur  at  night.  During 
these  paroxysms  the  pain  is  sharp,  burning,  and  lancinating.  In 
the  interval  it,  is  dull.  Besides  the  pains  the  patient  suffers  from 
feelings  of  numbness,  tingling,  and  a  sense  of  coldness  and  weight 
in  the  affected  limb.  There  are  almost  always  tender  points  over 
the  course  of  the  nerve.     These  may  be  found  at  the  sciatic  notch, 

*  Personal  statistics  (102  cases)  and  those  of  Dr.  J..  Putzel  (68  eases) 
give:  Males,  111  ;  females,  44.  A.ges:  10-20,  4;  21-30,  30;  31-40,  43;  41- 
50,  44;  51-60,  18;  61-70,  12;  71-80,  4. 


202 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


at  the  middle  of  the  hip,  behind  the  knee,  just  below  the  head  of 
the  fibula  in  the  middle  of  the  calf,  behind  the  external  malleolus, 
and  on  the  back  of  the  foot  (Fig.  99). 

A  pain  running  up  the  back  of  the  thigh  may  be  caused  by  pres- 
sure over  the  back  of  the  knee  when  the  leg  is  extended  at  a  little 
more  than  a  right  angle.  This  is  diagnostic  (Gowers).  If  the  pa- 
tient lies  on  his  back  and  the  leg  is  kept  extended,  and  then  the 
whole  limb  brought  slowly  up  until  it  is  at  an  acute  angle  with  the 
trunk,  a  sharp  pain  in  the  sciatic  notch  is  felt;  this  too  is  diagnostic. 
Anaesthesia  over  the  course  of  the  nerves  occurs  very  rarely.  When 
present,  it  indicates  a  severe  neuritis  or  injury  to  the  nerve.  Mus- 
cular wasting  and  weakness  occur  after  a  time,  and  in  old  and  severe 


Fig. 


99.— Showing  the  Tender 
Points  in  Sciatica. 


Fig.   100.— Plantar  Form  of  Sciatica;  Plantar 
Neuritis,  showing:  area  of  pain  (Mitchell;. 


cases  partial  electrical  degeneration  reactions  may  be  observed. 
Herpetic  eruptions  over  the  course  of  the  nerve  occur  in  rare  cases. 
The  affected  limb  usually  feels  colder  and  shows  evidence  of  en- 
feebled vasomotor  supply. 

The  disease  usually  lasts  two  or  three  months;  not  rarely  it 
lasts  six  months  or  even  a  year  or  more.  It  has  been  known  to 
extend  slowly  upward  and  involve  the  sacral  plexus  or  even  the 
spinal  cord. 

Pathology. — The  trouble  is,  as  already  stated,  a  chronic  peri- 
neuritis in  the  majority  of  cases. 

Diagnosis. — Sciatica  has  to  be  distinguished  from  hip-joint  dis- 
ease, organic  disease  of  the  cauda  equina  or  cord,  muscular  pains 
in  the  hip  and  leg,  and  from  pains  caused  by  tumors.  Pure  sciatic 
neuralgia  ought  also  to  be  distinguished  from  sciatic  neuritis.     A 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL   NERVES.       203 

consideration  of  the  facts  already  given  ought  to  make  the  diag- 
nosis not  difficult.  Pure  sciatic  neuralgia  occurs  in  early  life  and  is 
not  accompanied  by  much  local  tenderness.  There  is  no  paralysis 
or  wasting  of  the  limb.  Double  sciatica  is  most  always  symptomatic 
of  diabetes  or  organic  disease.     True  sciatica  is  rarely  double. 

Prognosis. — Almost  all  cases  get  well  in  from  three  to  six 
months.  Severe  attacks  in  people  over  forty  are  the  most  intrac- 
table.    Relapses  occur,  but  not  as  a  rule. 

Treatment. — In  all  cases  which  are  seen  early,  the  most  impor- 
tant indication  is  rest.  The  patient  should  be  put  to  bed,  and  the 
whole  lower  extremity  secured  in  a  Thomas  splint  extending  from 
ankle  to  axilla.  Ice  bags  or  linseed  poultices  or  leeches  should  then 
be  applied  over  the  course  of  the  nerve.  A  blue  pill  (gr.  v.)  may 
be  given  twice  daily  at  first.  In  less  severe  or  older  cases  large 
blisters  should  be  applied  over  the  nerve  in  the  thigh,  and  the  ap- 
plication repeated  in  a  week.  If  there  is  a  rheumatic  history, 
potassium  salicylate  or  iodide  should  be  given  in  full  doses.  The 
bowels  must  be  freely  opened.  Hypodermic  injections  of  morphine 
or  cocaine  (gr.  \)  may  be  needed  for  a  few  days,  the  cocaine  being 
repeated  if  necessary.  When  the  disease  has  become  more  chronic 
a  strong  galvanic  current  may  be  given  daily  with  large  electrodes, 
one  over  the  lumbar  region  or  sciatic  notch,  the  other,  which  should 
be  the  positive  pole,  over  the  leg  and  foot.  As  so-called  specific 
remedies  we  have  oil  of  turpentine  in  doses  of  fifteen  drops  t.  i.  d„, 
and  this  may  be  advantageously  combined  with  oil  of  gaultheria. 
Massive  doses  of  antifebrin  or  antipyrin  sometimes  stop  the  pains 
(gr.  x.,  q.  2  h.).  There  are  a  great  many  local  remedies  which  at 
times  prove  useful.  Among  these  mustard  plasters,  menthol, 
chloroform  liniment,  setons,  acupuncture,  cups,  and  the  actual 
cautery  and  chloride  of  methyl  can  be  recommended.  Bandaging 
the  limb  in  sulphur  to  which  a  little  menthol  is  added  is  often  very 
efficacious.  Kneading  the  nerve  with  a  glass  rod  and  an  anodyne 
ointment  is  sometimes  beneficial.  Very  little  can  be  expected  from 
nerve  stretching,  but  it  may  be  tried  as  a  last  resort.  If  tried, 
however,  great  caution  should  be  exercised  in  pulling  on  the  nerve. 
Not  over  thirty  to  forty  pounds  pull  should  be  used.  The  operation 
of  cutting  down  on  the  nerve  and  dissecting  off  the  sheath  for  a 
space  of  several  inches  may  be  tried. 

Plantar  Neuralgia. — In  rare  cases  the  pain  of  sciatic  neu- 
ralgia is  limited  to  the  plantar  nerves,  and  is  accompanied  by  par- 
esthesia and  even  amesthesia  of  this  region.  The  condition  here  is 
probably  a  neuritis  combined  sometimes  with  arthritic  changes. 
Erythromelalgia  may  be  regarded  as  a  form  of  plantar  neuralgia. 


204  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Erytheomelalgia  (  red  neuralgia  of  the  feet,  congestive  neu- 
ralgia) is  a  disease  affecting  the  feet  chiefly,  and  characterized  by 
burning  pains  and  congestion  of  the  parts. 

The  disease  occurs  usually  in  men  in  middle  life,  after  some 
fever  or  severe  physical  exertion  afoot.  It  is  due  sometimes  to 
gouty  habits,  and  I  have  seen  it  in  patients  who  were  diabetics. 

The  disease  begins  in  the  ball  of  the  foot  or  the  heel  with  burn- 
ing pains.  The  troiible  increases  until  nearly  the  whole  sole  in  the 
distribution  of  the  plantar  nerve  is  involved,  and  the  pain,  though 
worse  at  night,  is  almost  continuous.  It  is  much  increased  by  exer- 
tion, the  feet  become  very  tender,  and  standing  or  walking  is  most 
painful.  Meanwhile  there  has  developed  with  the  pain  a  flushing 
of  the  part  upon  exertion.  In  bad  cases  the  parts  most  affected  are 
continuously  marked  by  a  dull,  dusky,  mottled  redness,  with  some 
swelling.  The  hands  may  be  slightly  affected.  Slight  injuries 
may  cause  blisters  and  even  ulcerations.  The  congestion  usually 
disappears  in  the  horizontal  position,  and  this  also  relieves  the  pain. 
The  symptoms  are  worse  in  warm  weather.  The  disease  is  very 
chronic  and,  though  not  dangerous  to  life,  makes  life  very  miserable. 

Pathology. — In  the  cases  of  erythronielalgia  as  described  by 
Mitchell  and  others,  there  are:  (1)  A  vasomotor  disturbance;  (2)  a 
neuritis ;  and  (3)  in  rare  instances,  spinal-cord  disease ;  (4)  some- 
times there  is  an  obliterative  arteritis.  The  condition  in  my  expe- 
rience is  closely  associated  with  diabetes. 

The  diagnosis  must  be  made  from  alcoholic  and  gouty  paresthesia, 
podalgia,  local  disease  of  bone  and  ligaments,  and  from  reflex  pains. 

Treatment. — Elevation  of  the  feet  and  applications  of  cold  g;ve 
temporary  relief.  Faradization  has  sometimes  given  help ;  ofte \ier 
it  has  not.  There  is  nothing  known  which  gives  permanent  relief. 
The  physician  must  rely  upon  rest,  bandaging,  cold,  anodyne  aj (pli- 
cations, hydrotherapy,  and  tonics.  The  salicylates,  turpentine,  and 
mineral  acids  with  strychnine  may  be  given.  Benefit  in  lithjemic 
cases  is  obtained  from  codeine  and  an  antidiabetic  diet. 

Plantar  Neurosks  ok  Mechanical  Ortgin. 

Morton's  neuralgia,  so  called,  is  a  neuralgia  affecting  the 
metatarsophalangeal  joint  of  the  third  and  fourth  toes,  and  is  due, 
it  is  thought,  to  a  slight  luxation,  with  consequent  pressure  on  a 
digital  branch  of  the  external  plantar  nerve.  It  sometimes  affects 
other  toes,  however.  It  is  not  always  due  to  a  luxation.  Incipient 
flatfoot  may  cause  it,  and  I  have  seen  a  typical  case  in  a  pregnant 
woman,  disappearing  after  confinement.  The  trouble  occurs  gener- 
ally in  women,  and  if  there  is  a  luxation  the  cause  is  external  injury 


SENSORY    NEUROSES    OF   THE    CEREBRO-SPINAL    NERVES.       205 

or  shoe  pressure.  The  treatment  is  not  very  satisfactory.  It 
should  be  directed  to  giving  rest  to  the  foot,  and  the  avoidance  of 
lateral  pressure  on  the  joints  by  wearing  a  broad-soled  shoe  with 
support  to  the  arch  of  the  foot.  Support  may  also  Lie  given  by  a 
broad  flannel  bandage.  Amputation  of  the  toe  is  a  very  certain 
remedy. 

Tarsalgia  (policeman's  disease)  is  a  neuralgic  affection,  due 
probably  in  most  cases  to  an  incipient  flattening  of  the  foot  and 
stretching  of  the  plantar  ligaments.  Some  have  ascribed  it  to  a 
deep-seated  contusion  of  the  adipose  cushion  covering  the  os  calcis. 
A  chronic  inflammation  of  the  sheath  of  the  tendo  Achillis  causes 
symptoms  resembling  podalgia.  Probably  the  condition  varies 
somewhat  in  different  cases.  It  is  observed  in  persons  who  have 
been  in  the  habit  of  going  barefoot,  and  have  then  gone  into  the 
army  or  taken  civil  positions  obliging  them  to  stand  or  walk  a  great 
deal. 

It  was  noticed  originally  in  the  policemen  of  Paris,  and  cases 
have  been  seen  in  this  country.  The  name  tarsalgia  was  given 
by  Duchenne. 

Treatment,  medical  or  surgical,  seems  to  do  little  for  the  disorder, 
which  is  very  chronic.  Patients  are  better  in  cold  weather,  and 
when  resting  the  feet.  Leeches,  the  cautery,  the  iodides,  and 
broad  shoes  with  rubber  heels  are  serviceable. 

Coccygodyxia  is  a  neuralgia  affecting  the  lower  posterior 
brandies  of  the  sacral  nerves.  It  occurs  oftenest  in  women  and  is 
caused  by  exposure,  injury,  and  labor.  Coccygeal  pains  occur  in 
spinal  irritation  and  reflexly  from  pelvic  disease.  The  disease  is  a 
most  annoying  one,  as  it  interferes  with  sitting  and  walking.  There 
is  often  also  pain  at  stool,  and  the  parts  are  tender  to  pressure. 
The  disease  is  usually  one  involving  the  fibrous  structures  of  the 
coccyx,  and  is  more  an  articular  and  bony  than  a  nervous  disorder. 

Surgical   treatment,  such   as   amputation   of   tin ccyx,  may  be 

needed,  and  is  sometimes  effective,  but  not  in  the  cases  in  which 
there  is  only  a  neurasthenia  with  spinal  irritation. 

Periphbbax  Vasomotob  and  Trophic  Neub< 

Symmetrical  Angio-Neubotic  Gangrene,  ob  B  wvaid'.s 
Diseask  (Abortive  Fobm  Known-  as  Digit]  Mortui).-  Sym- 
metrical gangrene  or  Raynaud's  disease  is  a  rare  affection  charac- 
terized by  spasm  of  the  vessels  of  the  extremities,  coldness,  pallor, 
waxmess  of  fingers  or  toes,  or  by  blueness.  mottling,  swelling,  pain, 
followed  often  by  a  dry  gangrene  of  some  of  the  fingers  or  toes. 


206 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


Etiology. — The  disease  occurs  usually  in  children  and  young 
adults.  Women  are  affected  oftener  than  men.  Anaemia,  and 
chlorosis,  and  neurasthenic  states  predispose  to  it.  Malarial  in- 
fection, acute  infectious  fevers,  menstrual  disorders,  fright,  occu- 
pations that  lead  to  exposure,  such  as  washing,  are  causative  factors. 
Diabetes  and  syphilis  are  also  put  down  as  causes. 

Symptoms. — The  disease  comes  on  rather  suddenly  and  affects 
oftenest  two  or  three  fingers  of  both  hands.  In  its  early  and  mild  de- 
gree there  are  simply  a  coldness,  numbness,  and  waxy  pallor  of  the 
fingers.     The  skin  looks  shrunken.      There  is  slight  anaesthesia. 


Fig.  101.— Hand  and  Foot  in  the  Gangrenous  Stage  op  Raynaud's  Disease. 

The  extremities  feel  as  if  dead.  After  a  few  hours  this  passes 
away,  but  returns  again  and  may  finally  become  an  almost  constant 
condition.  Beginning  in  one  or  two  fingers,  it  may  finally  involve 
all.  The  toes,  tip  of  the  nose,  and  ears  may  be  similarly  affected, 
though  this  is  rare  in  the  milder  form.  Exposure  to  cold,  even 
slight,  is  the  common  excitant  of  this  form  of  the  trouble,  which  is 
commonly  known  as  "digiti  mortui,"  "dead  fingers,"  or  "local 
syncope." 

In  severer  grades  the  fingers  become  blue,  swollen,  and  there 
are  burning  sensations  and  much  pain,  but  no  anaesthesia.  This 
condition  is  known  as  that  of  "local  asphyxia,"  and  it  is  usually 
followed  by  gangrene. 

In  the  gangrenous  stage  small  blisters  appear  on  the  distal 
phalanges,  which  fill  with  bloody  serum,  then  dry  up,  and  beneath 


SENSORY    NEUROSES   OF   THE    CEREBRO-SPINAL   NERVES.       207 

the  scab  ulceration  begins,  which  is  shallow  and  soon  heals,  leaving 
a  scar.  The  process  then  stops.  In  very  rare  cases  the  Avhole  tip 
of  the  finger  or  toe,  including  the  bone,  becomes  involved.  The 
process  as  stated  may  attack  the  ears,  lips,  tongue,  and  even  parts 
of  the  trunk.  Along  with  this  gangrenous  process  there  is  often 
a  hasmaturia. 

The  dead-finger  trouble  may  last  but  a  few  days  or  weeks,  or  it 
may  continue  for  months.  The  gangrenous  stage  lasts  about  three 
weeks.  It  lasts  longer  if  it  comes  on  in  one  finger  after  the  other. 
The  disease  is  one  of  months,  and  it  is  liable  to  recur. 

The  diagnosis  must  be  made  from  senile  gangrene,  frostbite, 
ergot  poisoning,  alcoholic  neuritis,  endarteritis,  and  obstruction  of 
nutrient  vessels. 

Pathology. — A  neuritis  has  been  found  in  some  cases  of  so-called 
Raynaud's  disease,  but  this  is  secondary.  In  a  few  other  cases 
there  has  been  found  an  obliterating  endarteritis  (Jacoby).  The 
trouble  is  in  some  cases  apparently  functional  and  due  to  the  com- 
bination of  an  oversensitive  nervous  system  and  some  irritant,  such 
as  impoverished  blood,  malaria,  or  other  toxic  agent,  which  causes 
spasm  of  the  peripheral  vessels. 

Prognosis. — The  cases  usually  get  well,  but  the  course  is  long 
and  there  may  be  relapses.  In  only  the  rarest  instances  has  death 
occurred,  and  then  from  some  complication. 

Treatment. — Galvanism  to  the  spine  and  limbs,  warm  applica- 
tions, anodynes,  tonics,  are  indicated.  Nitroglycerin,  the  iodides, 
chloral  may  be  tried.     No  specific  is  known. 


CHAPTER  XL 

DISEASES   OF   THE    SPINAL   COED. 
Anatomy  and  Physiology. 

Anatomy. — The  spinal  cord  is  a  slender,  cylindrically  shaped 
organ.  It  is  from  42  to  45.7  cm.  (sixteen  and  one-half  to  eighteen 
inches)  long,  being  shorter  absolutely  and  relatively  in  women.  Its 
weight  is  about  thirty -three  grams  (one  ounce).  It  is  suspended 
in  the  vertebral  canal,  where  it  reaches  in  all  persons  over  one  year 
of  age  as  far  down  as  the  second  lumbar  vertebra.  In  new-born 
infants  it  extends  to  the  third  lumbar  vertebra. 

It  is  divided  into  cervical,  dorsal  or  thoracic,  lumbar,  and  sacral 
portions,  corresponding  with  the  nerves  it  gives  off.  These  are  re- 
spectively four,  ten  and  one-half,  two,  and  one  and  one-half  inches 
long  (see  Fig.  102).  Its  shape  on  cross-section  is  nearly  round,  ex- 
cept in  the  lower  cervical  region,  where  it  is  flattened  antero-pos- 
teriorly.  Its  average  diameter  is  1  cm.  (two-fifths  of  an  inch) .  It 
has  two  swellings  or  enlargements,  the  cervical  and  lumbar.  Their 
positions,  size,  and  extent  are  shown  on  the  diagram.  Its  specific 
gravity  is  1.030. 

It  is  surrounded  by  three  membranes,  all  of  which  are  continu- 
ous with  the  corresponding  envelopes  of  the  brain.  They  are  the 
dura  mater,  the  arachnoid,  and  the  pia  mater  (Fig.  103). 

The  dura  mater  is  the  external  covering.  It  is  a  long  sac  at- 
tached to  the  edge  of  the  foramen  magnum  above  and  extending 
down  until  its  walls  fuse  together  at  the  level  of  the  second  sacral 
vertebra.  Its  cavity,  therefore,  is  much  longer  than  the  spinal 
cord.  It  is  attached  to  the  bony  canal  at  its  lower  end,  and  is  held 
loosely  by  twenty-two  lateral  ligaments  (I.  denticidata)  throughout 
its  length. 

The  arachnoid  is  a  thin,  semitransparent  membrane  lying  loosely 
over  the  cord  and  roots. 

Internally  this  is  connected  by  numerous  connective-tissue  fila- 
ments with  the  innermost  membrane,  the  pia  mater.  The  latter  is 
a  thin  vascular  sheath  applied  closely  to  the  cord  and  roots.  The 
space  between  the  dura  and  arachnoid  is  called  the  arachnoid  cav- 
ity. It  contains  a  very  little  cerebro-spinal  fluid.  That  between 
the  arachnoid  and  pia  is  called  the  subarachnoid  cavity ;  it  contains 
a  good  deal  of  cerebro-spinal  fluid.  Both  cavities  connect  with 
those  of  the  brain  and  probably  with  each  other.  The  dura  has  a 
mechanical  protective  function,  the  arachnoid  a  serous  and  the  pia 
a  vascular  function. 


DISEASES    OF   THE    SPINAL    CORD. 


209 


The  spinal  cord  is  movable  in  its  canal  to  the  extent  of  from  one- 
half  to  one  inch. 

Thf  Nerve   limits. — The  spinal  nerve  roots  are  covered  with  the 
pia  and  arachnoid.     They  pierce  the  dura  in  two  places  and  unite 

to  form  a  mixed  nerve.  The  dura  mater 
is  prolonged  over  the  nerves  as  they  pass 
through  it,  forming  a  tubular  sheath.  The 
anterior  roots  are  the  larger.  At  the 
point  of  exit  of  the  nerves  from  the  cord  a 
slight  constriction  is  formed. 

The  Hunt  Ganglia.  —  On  each  posterior 
root,  outside  thf  dura,  is  a  posterior  spinal 
ganglion.  The  ganglia  lie  in  the  inter- 
vertebral canals,  except  those  on  the  sacral 
nerves. 

Fissures.  —  Throughout  the  whole 
length  of  the  cord  there  are  two  median 


Oi2 


-  u 

II 

►J  .2 

a 
9 


Conus 

•*•'      medullaris 


Filum 
terminate. 


Fir;.  102.—  Showing*  thk  Rkla- 
tive  Si/.k  OF  the  Different 
Parts  of  the  Cord  (After 
Allen). 


Fiii.  108.  V,  Spinous  process;  i".  body  at  vertebra; 
i.  Ugamenl ;  '-'.  vessels;  3,  dura  mater  with  the  arachnoid 
lying  dlrectlj  beneath  It;  i.  anterior  root;  6,  posterior 
pool :  6,  spinal  ganglion  ;  7,  ligament 


fissures,  called  the  anterior  and   posterior. 

Columns. — These  fissures  and  the  lines  formed  by  the  exit  of 
the  roots  divide  the  cord  into  four  columns — anterior,  posterior,  and 
two  lateral. 

The  Composition  of  the  Cord.-  -The  cord  is  composed  of  white 
and  gray  matter.  The  white  matter  lies  outside  and  is  composed 
14 


210 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


mainly  of  nerve  fibres,  the  gray  matter  mainly  of  nerve  cells. 
Each  has  also  neuroglia,  connective  tissue,  and  blood-vessels.  In 
the  gray  matter  in  a  central  canal  lined  with  epithelial  cells. 


Format  ret/cut. 


First  Cervical. 


Second  Cervical. 


Interme.^  cells 
Fasc    cune at. 

Fasc.  gracilis  ^S. 


Comrnls.  cb/Is 
Med.  motor  cells 

I. at.  motor  cells 
Sixth  Cervical. 


Clork'-S    Col. 
Su6st.  ge.la.ttn. 
zrftr. 

Subst.  gelatin.  \  W?|sfc  ■ 


J/Ssura    atxtl 

Commiss.  ce//a 

~Motor  cells' 

Lateral  horn. 

First  Dorsal. 


Fig.  104  a.—  Showing  Arrangement  of  Gray  and  White  Matter  at  Different  Levels 
of  the  Cord  (After  Merkel). 


The  gray  'matter  is  arranged,  as  shown  in  the  figures,  somewhat 
in  the  shape  of  a  letter  H.  Its  different  parts  are  called  the  an- 
terior and  posterior  horns  and  intermediate  gray.  At  certain  levels 
there  are  lateral  horns.     The  gray  matter  changes  in  shape  at  dif- 


DISEASES   OF   THE   SPINAL    CORD. 


211 


ferent  levels  of  the  cord.  It  is  greatest  in  amount  at  the  lumbo- 
sacral junction  (23.33  sq  mm.);  next  at  the  cervical  enlargement 
(sixth  cervical)  (17.32  sq.  mm.).  It  increases  in  amount  relatively 
to  the  white  matter  from  above  downward  (Fig.  104).  The  gray- 
matter  of  the  two  halves  of  the  cord  is  connected  by  a  bridge  or 
commissure.  The  anterior  part  is  composed  chiefly  of  white  med- 
ullated  nerves,  and  is  called  the  white  commissure.  The  posterior 
is  composed  of  very  fine  nerve  fibres,  mostly  medullated  collaterals, 


Post,  column 


C/ar/i^    Col. 


/Int.  Col. 
Eighth  DorsaL 


Ant.  root 
First  Lumbar. 


C/arfCs  col. 


Third  Sacral. 


Z,ateral>.celia 
Comm.ss.ce/H        ^d/an    ce,/s 

First  Sacral. 
Fig.  104  b. -Showing  Arrangement  of  Gray  and  Whot  Matter  at  Dikkkuknt  Levels 
of  tiik  Cord  <  a tr.-i-  U< 


called  the  gray  commissure.  Between  the  two  is  the  centra]  canal, 
and  surrounding  it  is  the  central  gelatinous  substance^  composed  of 
neuroglia. 

The  posterior  horns  reach  to  the  periphery.     They  are  divided, 
beginning  from  without,  into  the  rim   zone  or  Lissauer's  column, 


212  DISEASES    OF  .THE    NERVOUS   SYSTEM. 

the  spongy  zone,  and  the  gelatinous  substance  of  Rolando.  The 
riin  zone  is  composed  of  very  fine  nerve  fibres ;  the  spongy  zone  and 
gelatinous  substance  are  composed  of  very  small  nerve  cells,  some 
having  continuous  neuraxons  (cells  of  Deiter)  and  some  having 
rapidly  branching  neuraxons  (cells  of  Golgi).  The  substance  of 
Rolando  is  extremely  rich  in  nerve  cells  and  is  not  made  up  of 
neuroglia,  as  was  once  supposed. 

To  sum  up,  we  have  the  gray  matter — 

Arranged  in  :  Composed  of : 

(  anterior,  a.    A  ground  substance  of  neuroglia  and  con- 

1.  Horns    \  lateral,  nective   tissue   forming  the  substantia 

(  posterior.  spongiosa. 

2.  Intermediate  gray.  b.   Cell  groups  :  internal,  anterior,  etc. 

c.  Plexuses  of  fine  nerve  fibres,  e.g. ,  in  the 

rim  zone. 

d.  Masses  of  neuroglia : 

(1)  The  central  gelatinous  substance. 

(2)  The  periphery  of  the  cord  and  the 
spongy  zone. 

6,    Blood-vessels  and  connective  tissue. 

Now,  taking  up  some  of  these  factors  in  detail,  we  find  that : 

(a)  The  ground  substance  of  the  gray  matter  is  made  up  of  a 
fine  meshwork  of  fibres  which  are  the  processes  of  neuroglia  cells 
and  of  nerve  cells.  Besides  this,  there  is  some  connective  tissue, 
and  there  are  prolongations  from  the  base  of  the  epithelial  cells 
lining  the  central  canal  (Fig.  105). 

(b)  The  nerve  cells  are,  in  part,  arranged  in  groups  with  the 
long  axis  parallel  to  that  of  the  cord.  The  cells  are  surrounded  by 
a  rich  plexus  of  dendrites  and  end  brushes,  as  well  as  by  the  sup- 
porting neuroglia  matrix,  a  little  connective  tissue,  and  many  small 
blood-vessels.  The  cell  groups  are  named  in  accordance  with  their 
position — internal,  antero-lateral,  lateral,  median,  posterior  or  sen- 
sory cells,  and  the  cells  of  Clark's  column  (Fig.  104). 

This  nomenclature  answers  for  ordinary  anatomical  descriptions. 
Histologically  we  find  two  kinds  of  cells,  the  root  cells  and  column 
cells  (Strangzellen).  The  former  are  those  cells  whose  neuraxons 
pass  out  to  form  the  anterior  roots.  They  form  the  great  part  of 
the  anterior  horns.  Deep  in  the  anterior  horns  are  a  few  root  cells, 
whose  neuraxons  pass  into  the  posterior  roots  and  thence  to  the 
ganglionic  system.  The  column  cells  are  found  in  the  posterior 
horns,  intermediate  gray,  and  to  some  extent  in  the  anterior  horns. 
Their  neuraxons  pass  to  the  white  matter  of  the  same  or  opposite 
side,  and  furnish  commissural,  associative,  and  even  long  column 
fibres. 

The  anterior-horn  root  cells  are  arranged  in  groups  which  over- 
lap each  other.  Each  group  has  the  special  duty  of  presiding  over 
certain  sets  of  muscles  or  other  organs  which  have  a  common  func- 
tion. These  cells  are  large  in  size,  35  to  100//  (TiT  to  ^  in.); 
they  are  multipolar,  having  five  or  six  processes,  one  of  which  is 
an  axis-cylinder  process,  which,  in  lower  animals  at  least,  gives  off 


DISEASES    OF   THE    SPINAL   CORD. 


213 


a  collateral  before  it  leaves  the  cord.  The  cells  in  the  central  parts 
of  the  horn  are  the  smaller;  the  cells  in  the  lumbar  swelling  are 
largest,  because  they  are  connected  with  long  nerves.  The  cells  of 
the  cervical  swelling  are  next  in  size.  The  cells  of  the  posterior 
horn  are  small  and  multipolar.  The  cells  of  Clark's  column  are 
bipolar,  30   to   <3< >/x  (-g-J-ij  to  ffo  in.)  in  diameter,  and  are  arranged 


Fig.  105. — Showing  the  Neuroglia  Groundwork  in  an  Embryonic  <'<>k!>. 


with  their  long  diameter  parallel  to  the  axis  of  the  cord.  They  are 
grouped  together  in  a  kind  of  nest  at  the  inner  and  central  part  of 
the  posterior  horn  (see  Fi.ur-  lr>4).  Clark's  column  is  most  distinct 
from  the  eighth  dorsal  to  the  second  lumbar  nerves,  but  extends  1151 
as  far  as  the  Inst  cervical.  An  analogous  group  of  cells  is  found  at 
the  level  of  the  second  and  third  sacral  nerves.  A  small  group  of 
spindle-shaped  cells  lies  in  the  intermediate  gray  matter  at  the  base 

of  the  posterior  horns.  There  are  other  minor  groups  of  Cells  which 
it  is  not  necessary  to  describe  here. 

The  white  matter  of  tin-  cord  is  composed  mainly  of  neuraxons 
and  the  collaterals  of  these  running  in  a  supporting  network  of 
neuroglia  connective  tissue,  and  blood-vessels.  Surrounding  it, 
ami  lying  just,  beneath  the  pia  mater,  is  a  thin  layer  of  neuroglia 
5  to  50//  {-.},  ,r  to  -.',;-  in.)  thick.  The  neuraxons  are  medullated,  hut 
have  no  neurilemma,  and  but  few,  if  any,  nodes  of  Ranvier.  There 
are  two  kinds:  the  large  (81    to  20/x)   and   the  .small   (2  to  '.'>■  m 


21-4 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


diameter).  The  small  fibres  make  up  the  postero-internal  (GollV) 
column  entirely,  and  are  numerous  in  the  deep  part  of  the  lateral 
columns,  but  they  are  found  iD  all  regions.  The  fibres  run  up  and 
down  for  the  most  part,  but  constantly  send  off  branches  to  the 
gray  matter.  They  are  arranged  in  columns,  the  division  being 
based  partly  on  anatomical,  partly  on  physiological,  and  partly  on 
embryological  grounds. 

Anatomically  there  is  a  simple  and  natural  division,  which  we 
have  already  given,  into  the  anterior,  lateral,  and  posterior  columns, 
the  divisions  being  made  by  the  median  fissures  and  the  roots  of  the 
nerves. 

On  physiological  and  embryological  grounds  the  columns  are 
further  subdivided  as  follows : 


The  anterior  columns 
are  divided  into 


Direct  pyramidal  tract. 
Anterior  fundamental  column. 


The  lateral 
columns  are 
divided  into 


The  posterior 
columns  are 
divided  into 


Lateral  fundamental  columns. 
Lateral  limiting  layers. 
Crossed  pyramidal  tracts. 
Direct  cerebellar  tracts. 

Antero-lateral  ascending  and  descending  tracts,  or  Gowers' 
column. 

Postero-internal  column,  or  column  of  Goll. 

Burdach's  column  is  divided 
Postero-external  columns, 
or  column  of  Burdach. 


The  ventral  zone. 
The  comma. 
The  oval  zone. 
The  triangular  column. 
.  Rim  zone,  or  column  of  Lissauer 


into 
Middle  root  zone. 
(_  Posterior  root  rone. 


The  fibres  which  make  up  these  columns  are  of  two  kinds — long 
or  projective,  short  or  associative. 

The  long  fibres  connect  the  different  levels  of  the  cord  with  the 
brain,  and  the  posterior  spinal  ganglia  with  nuclei  in  the  upper  part 
of  the  cord. 

The  short  or  associative  fibres  connect  different  levels  of  the 
cord  with  each  other,  and  also  connect  the  two  halves  of  the  cord 
at  the  same  levels. 

The  names  of  the  long-fibre  tracts  are  the  direct  and  crossed 
pyramidal,  the  direct  cerebellar,  the  antero-lateral  ascending,  and 
the  postero-internal  or  column  of  Goll. 

The  direct  pyramidal  tract  lies  along  the  anterior  median  fissure 
and  extends  down  as  far  as  the  lower  part  of  the  dorsal  cord.  Its 
fibres  cross  over  in  the  anterior  commissure  at  various  levels  and 
connect  with  the  cells  of  the  anterior  horns. 

The  crossed  pyramidal  tract  extends  down  the  whole  length  of 
the  lateral  column  of  the  cord  and  sends  its  fibres  to  the  anterior 
horns  of  the  same  side. 


DISEASES   OF    THE    SPIXAL   CORD. 


215 


jfsiooQ 


First  Lumbar. 


Sixth  Cervical  Segment. 


JtJJ.  JasT. 


r/sj.si/i?- 

First  DorsaL 


I' A 

mm 


wig?. gaaR 


Fourth  SacraL 


'-yoj 


Eighth  Dorsal. 


First  Sacral. 


Flo.  106.  —  Showing  the  Arrangement  op  the  Gray  and  the  White  Matter  Af 
Different  Levels  of  the  Cord,  also  the  columns  and  cell  groups. 


216  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Both  of  the  above  tracts  are  continuations  of  the  anterior  pyra- 
mids or  motor  tracts  of  the  medulla.  These  pyramids  divide  at  the 
lower  end  of  the  medulla,  about  ninety  per  cent  of  fibres  crossing 
over  to  form  the  crossed  pyramidal  tract  and  ten  per  cent  contin- 
uing on  the  same  side.  Some  of  the  fibres  of  the  crossed  pyramid 
redecussate  (in  lower  animals)  and  enter  the  pyramidal  tract  of  the 
side  on  which  they  started. 

The  divert  cerebellar  tract  begins  at  the  level  of  the  first  lumbar 
nerves.  Its  fibres  originate  in  the  vesicular  column  of  Clark. 
They  pass  up  to  the  cerebellum  and  go  chiefly  to  the  vermis.  Most 
of  them  then  cross  over  and  enter  the  red  nucleus. 

The  antero-lateral  ascending  column  extends  nearly  the  whole 
length  of  the  cord.  Its  fibres  come  from  the  anterior  commissure 
and  the  sensory  cells  of  the  opposite  posterior  cornu.  They  pass 
up  and  end  in  the  lateral  nucleus. 

The  postero-intemal  ml  mini,  or  column  of  Goll,  is  composed  of 
fibres  which  originate  in  the  ganglia  of  the  posterior  roots,  pass 
inward,  and  without  crossing  ascend,  to  end  in  a  nucleus  at  the 
\xpper  limit  of  the  cord,  the  nucleus  of  doll's  column  (postero- 
internal nucleus).  The  column  extends  the  whole  length  of  the 
cord.  It  is  very  small  in  the  sacral  region,  but  increases  in  size  as 
it  passes  up. 

There  are  a  few  long  fibres  scattered  in  the  anterior  and  lateral 
ground  bundles.  They  degenerate  down  and  are  called  the  antero- 
lateral descending  tract. 

The  names  of  the  shart-jibre  columns  are  the  anterior  and  the 
lateral  fundamental  columns,  the  lateral  limiting  layer,  and  the 
column  of  Burdach.  This  latter  column  contains  in  its  cervical 
part  some  long  fibres  which  end  in  a  nucleus  at  the  upper  limit  of 
the  cord,  the  postero-external  nucleus  of  the  column  of  Burdach. 

The  posterior  columns  also  contain  three  short-fibre  columns 
whose  cells  of  origin  lie  in  the  gray  matter  of  the  cord.  The  fibres 
in  the  cervical  region  lie  in  the  shape  of  a  comma  (comma  of 
Schultze),  in  the  lumbar  region  in  the  shape  of  an  oval  (oval  zone 
•of  Blechsig),  in  the  sacral  zone  in  the  shape  of  a  triangle  (triangle 
of  Gombault) .  Besides  this  there  is  a  zone  of  short  fibres  lying 
close  to  the  gray  commissure  the  whole  length  of  the  cord — ven- 
tral zone  or  posterior  fundamental  column. 

The  Belations  of  the  Different  Barts  of  the  Spixal 
Cord  to  the  Beripheral  Nerves,  to  the  Braix,  and  with 
Each  Other. — I  will  begin  with  a  description  of  the  way  in  which 
the  anterior  and  posterior  nerve  roots  are  connected  to  the  cord ; 
then  describe  the  mode  in  which  the  different  columns  and  cell 
groups  are  connected  with  each  other;  and  finally  I  will  indicate 
briefly  the  connections  of  the  cord  with  the  brain. 

The  anterior  nerve  roots  are  connected  directly  with  the  anterior- 
horn  cells,  of  which  they  are  processes,  and  together  with  which 
they  form  the  peripheral  motor  neurons.  It  is  possible  that  in  man 
they  send  off  collaterals  before  leaving  the  cord. 


DISEASES    OF   THE   SPINAL   CORD. 


217 


The  cells  of  the  anterior  horn  are  surrounded  by  two  chief  sets 
of  "end  brushes,"  one  coming  from  the  pyramidal  tracts,  the  other 
from  the  posterior  horns  aud  roots.  Thus  these  cells  are  in  re- 
lation with  impulses  from  the  brain  and  from  the  periphery. 

The  posterior  nerve  roots  originate  in  the  spinal  ganglia.  On 
entering  the  cord  the  fibres  divide  like  a  T  and  pass  up  for  one  or 
more  inches,  and  down  for  a  short  distance  only.  They  then  enter 
(1)  the  column  of  Goll,  (2)  the  anterior  and  posterior  commissure,  or 
(3)  the  posterior  horn.     They  all  send  off  collaterals,   and  termi- 


Fig.  107.— Showing  the  Cells  of  Origin  of  the  Motor  Nerves  in*  the  Anterior 
Horns  of  the  Spinal  Cord,  and  the  Cells  of  Origin  of  the  Sensory  Nerves  IN  the 
POSTERIOR  Spinal  Ganglia  (Van  Gehuchten). 


nate  eventually  in  end  brushes  surrounding  nerve  cells,  which  form 
their  terminal  nuclei.  These  root  fibres,  with  their  cells  of  origin 
and  the  sensory  nerve  fibres,  form  the  peripheral  sensory  neurons. 
There  are  at  least  three  groups  of  nerve  fibres  which  enter  by 
the  posterior  roots  and  make  different  connections  with  the  cell 
groups  or  columns : 

1.  An  innermost  set.  These  pass  across  the  postero-external 
column  and  enter  the  median  or  Goll's  column,  which  they  ascend, 
to  end  in  the  nucleus. 

2.  A  median  set.  These  pass  along  the  inner  side  of  the  pos- 
terior horn,  and  end  either  (a)  in  cells  of  the  deeper  part,  (b)  in  the 
spindle-shaped  cells,  or  (<•)  go  to  the  anterior  horn;  still  others  ('/) 
•ross  over  in  the  commissure  to  enter  the  anterolateral  tract. 

3.  An  outer  set.  These  are  very  line  fibres  which  enter  the  tip 
or  outer  part  of  the  posterior  horn,  and  then  run  up  and  down, 
forming  the  rim  zone.  They  eventually  connect  in  the  usual  way 
with  the  sensory  cells  of  the  posterior  horn. 

The  different  parts  of  the  spinal  cord  are  connected  by  the  short 
fibres  which  unite  different  levels  of  the  cord,  and  by  commissural 
fibres  which  unite  the  different  halves  of  the  cord.     These  short, 


218 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


and  commissural  fibres  originate  in  groups  of  nerve  cells  lying  in  the 
central  parts  of  the  gray  matter  and  are  called  associative  or  column 
nerve  cells.     They  are  small  and  multipolar.     Some  are  distributed 

sparsely  in  the  white  col- 
umns. Fibres  arise  from 
them,  run  in  the  com- 
missures and  short-fibre 
tracts,  and  end  in  brushes 
which  put  the  fibres  in 
relation  with  various  cell 
groups  (Figs.  109,  110). 


Physiology. — The  de- 
tailed facts  regarding  the 
functions  of  the  spinal 
cord  may  be  gotten  in 
physiological  text-books. 
I  shall  give  only  those 
bearing  more  or  less  di- 
rectly on  the  localization 
of  the  functions.  The 
spinal  cord  is  a  conductor 
and  centre  of  nervous 
action.  It  represents  the 
lowest  evolutionary  level 
of  the  development  of  the 
nervous  system.  Its  func- 
tions, so  far  as  they  are 
independent,    are    stable 


Fig.  108.— Schematic  Drawing  of  Sexsory  Tracts. 


y,.  Spinal  ganglion  cell  with  one  neuraxon  going  in  the  ana    Wq\\    organized,    but 
peripheral  nerves  to  the  skin  8,  and  with  one  in  the  pos-       «  V>  1  1-1 

terior   root;    1,  fibres  of  the  posterior   root,  ascending  °}  a  mecnanical  ana  reia- 

partly  in  the   posterior  column  (2),  partly  entering  the  tively  simple  order, 
posterior  horn  ;  {/2,  cell  of  Clarke's  column,  passing  from  Functions  of  the.  White 

this  to  the  cerebellar  tract  (3);  g3,  ganglion  cell  in  gray  .-,  ,  TVi  i  ■(.„ 

matter,  sending  fibres  (4)  to  Gowers'   tract;  a6,  cell  in  Columns.       ine       WU1  te 

nucleus  gracilis   in  medulla  oblongata ;    from  posterior  matter  is    a   conductor   of 

root  fibres  also  pass  to  f/4,  anterior  horn  ganglion  cell.  nerve    impulses      and    its 

functions  are  relatively 
simple.  We  have  only  to  study  the  direction  and  kind  of  impulses 
carried  by  its  various  columns.  The  direct  and  crossed  pyramidal 
tracts  originate  from  cells  in  the  motor  cortex  of  the  brain.  They 
carry  motor  impulses  downward  from  the  brain.  The  crossed  pyra- 
midal tract  crosses  in  the  medulla  to  the  side  opposite  to  that  where 
it  originates,  and  passes  down  the  lateral  column  to  connect  the  motor 
cells  of  the  anterior  horns.  The  direct  pyramidal  tract  runs  along 
in  the  anterior  column,  and  at  different  levels  sends  fibres  across 
through  the  anterior  commissure  to  the  motor  cells  of  the  anterior 
horns.     These  tracts  normally  exercise  a  continual  inhibitory  in- 


DISEASES    OF   THE    SPINAL    CORD. 


219 


fluence  on  the  motor  cells  of  the  anterior  horns,  so  that  when  de- 
stroyed there  develop  spasmodic  conditions  of  the  paralyzed  part. 

The  anterior  (/round  bundle,  lateral  ground  bundle,  and  lateral 
Um  vting  layer  have  the  function  of  associating  different  levels  of  the 
cord  and  of  connecting  it  also  with  nuclei  in  the  medulla  and  centres 
in  the  cerebellum. 

The  columns  of  Goll  conduct  special  sensations  from  the  muscles, 
articulations,  and  tendonous  sheaths  via  the  root  on  the  same  side. 
When  diseased,  there  is  a  loss  of  the  sense  of  position  of  the  limbs, 
of  the  power  of  estimating  weights,  and  of  co-ordination  of  muscular 
effort  (ataxia).     The  fibres  cross  over  in  the  medulla. 


Fig.  109. 


Fig.  110. 


Fig.  109.— Showing  the  Connections  of  the  Anterior  and  Posterior  Roots  and 
Cornla  with  Each  Other  (Cajal).  .4.  Anterior  root;  B,  posterior  root;  «,  collaterals; 
d,  end-brushes. 

Fig.  110.— Showing  the  Association  or  Short-Fibre  System  of  the  Cord  (Cajal). 
■7,  Anterior  cornua  cell;  6,  c,  <l,  association  fibres;  <-,  posterior  association  fibres. 


The  mlu in ns  of  Burdock  conduct  to  a  certain  extent  tactile 
sensations  coming  in  from  the  opposite  posterior  root.  They  also 
contain  many  associative  fibres,  connecting  different  levels.  Tain- 
sense  fibres  and  excito-reflex  fibres  from  the  posterior  roots  run 


220  DISEASES    OF    THE    NERVOUS    SYSTEM. 

through  these  columns  to  reach  the  commissure  or  the  anterior 
horns;  other  fibres  run  through  it  to  Clark's  column  and  to  the 
column  of  Goll.  Hence  it  is  a  pathway  for  all  kinds  of  afferent 
impulses.  When  diseased,  there  may  be  pain,  anaesthesia,  ataxia, 
and  loss  of  reflexes.  The  fibres  cross  over  at  once  to  the  oppo- 
site side.  The  direct  cerebellar  tracts  carry  impulses  to  the  cere- 
bellum which,  assist  in  maintaining  equilibrium. 

The  antero-lateral  ascending  tract  conducts  sensations  of  pain 
and  temperature,  coming  in  from  the  opposite  side,  through  the 
anterior  commissure. 

There  are  considerable  variations  in  the  paths  of  conduction  of 
tactile  temperature  and  pain  sensations,  and  their  exact  position  is 
not  positively  known.  In  transverse  lesions  of  the  cord  these  tracts 
do  not  degenerate  upward  so  completely  or  uniformly  as  do  second- 
ary degenerations  of  other  long-fibre  tracts.  Hence  they  probably 
receive  some  interruptions  in  their  course.  In  fact,  it  is  probable 
that  the  paths  for  these  impulses  are  very  wide  and  not  arranged 
in  a  compact  bundle  like  the  motor  tract. 

The  gray  ■mutter  contains  chiefly  cell  groups  which  act  as 
centres  and  distributors  of  nerve  impulses.  In  the  anterior 
hor  us  the  cells  have  a  motor  and  trophic  function.  The  larger 
cells  are  at  the  outer  parts  of  the  horn  and  send  fibres  to 
the  larger  skeletal  muscles.  The  more  central  cells  are  con- 
nected with  small  muscles  and  those  having  more  delicate  func- 
tions and  adjustments.  In  the  still  more  central  and  interme- 
diate part,  also,  are  separate  trophic  cells  for  the  muscles,  bones, 
and  joints,  and  cell  groups  which  preside  over  vasomotor  and  secre- 
tory functions.  Among  these  groups  are  the  spindle-shaped  cells, 
which  send  fibres  to  the  vasoconstrictors  (Gaskill),  throiigh  the 
anterior  (Hill)  and  perhaps  posterior  roots  (Gaskill).  The  cells  of 
Clark's  column  receive  fibres  from  the  viscera.  Impulses  pass  to 
these  cells  and  thence  to  the  direct  cerebellar  tract  and  cerebellum. 
Their  function  is  to  conduct  impulses  from  the  viscera  relating  to 
equilibrium  and  sense  of  position.  They  are  analogous  to  the 
fibres  of  the  column  of  Goll.  According  to  Gaskill,  Clark's  column 
is  a  centre  for  the  vasodilators.     This  is  unlikely. 

Automatic  Centers. — The  nerves  and  cells  of  the  cord  are  ar- 
ranged in  complex  groups  which  preside  over  certain  functions  or 
respond  in  a  definite  way  to  certain  stimuli.  These  are  called  the 
spinal  automatic  centres.  They  are  the  cilio-spinal,  secretoiy, 
vasomotor,  genital,  vesical,  and  rectal.  The  important  parts  of 
these  centres  lie  deep  in  the  gray  matter  on  either  side  of  the  cen- 
tral canal,  but  nearer  the  base  of  the  posterior  horns.  Lesions 
of  the  white  matter,  or  of  the  anterior  or  posterior  horns,  do  not 
directly  affect  them. 

The  cilio-spindl  centre  reaches  from  the  seventh  cervical  to  the 
second  dorsal  segment,  inclusive.  Its  stimulation  causes  the  pupils 
to  contract. 


DISEASES    OF   THE    SPINAL    CORD. 


221 


The  genital  centres,  including  those  for  erection  and  ejaculation, 
reach  from  the  first  to  the  third  sacral  segment,  inclusive. 


Fig.  111.--Showixo  the  Relation*  of  the  Brora*  j  PROOxasES  to  thb  Ponraa  of  Oeioim 

IN  THE  Coao  OF  TH«  Sl'I.NAL  Nntvi  - 


The  bladder  and  rectal  centres  are  in  the  fourth  and  fifth  sacral 

segments,  extending  up  and  down  a  short  distance,  the  bladder 
being  perhaps  a  little  lower. 

The  spinal  vasomotor  centres  extend  from  the  second  dorsal  to 


222 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


the  second  lumbar  segments.  The  vasodilator  nerves  pass  out  by 
the  anterior,  the  constrictor  by  the  posterior  root  (Gaskill). 

The  cells  of  the  posterior  horns  are  sensory  in  function  and  are 
connected  with  the  tactile,  pain,  temperature,  and  reflex  fibres  of 
the  posterior  roots. 

The  trophic  centres  for  the  joints,  hones,  and  skin  apparently  lie 
near  the  posterior  horns.  Their  fibres  pass  out  by  the  posterior 
roots. 

Topography  and  Localization. — The  neurologist  and  surgeon  need 
to  know,  for  purposes  of  diagnosis  : 

1.  The  relation  of  the  spinal  nerve  roots,  at  their  point  of 
origin,  to  the  spinous  processes.  This  is  shown  in  the  figure  (p. 
221).  In  general  it  will  be  seen  that  the  different  pairs  of  nerve 
roots  arise  opposite  the  spinous  process  of  a  vertebra  one  or  two 
segments  above  those  between  which  it  makes  its  exit.  Thus  the 
sixth  cervical  originates  opposite  the  fourth  cervical  spine,  the  sixth 
dorsal  between  the  third  and  fourth  dorsal  spines,  the  first  lumbar 
between  the  eleventh  and  twelfth  dorsal  spines.  There  is  consider- 
able variation  in  these  relations. 

2.  The  next  points  desired  are  the  special  function  of  each  pair 
of  nerve  roots  anterior  and  posterior,  and  the  level  of  the  various 
centres  in  the  cord.  This  is  shown  in  the  following  table,  based  on 
that  originally  devised  by  Starr,  modified  by  Mills,  Sachs,  and  my- 
self f-.-jin  personal  experiments  and  the  clinical  and  pathological  ob- 
servations of  Thorburn  and  others. 

Muscles  op  Tongue,  Palate,  and  Pharynx. 


Diseases  in 

Name  of 

Normal 

Symptoms  of  Defi- 

Innervated 

Represented 

ivhich  Muscle  is 

Muscle. 

Function. 

cient  Action. 

by 

in 

commonly  In- 
volved. 

6  e  n  i  o  • 

Pushes  tongue 

Tongue  when  pro- 

The twelfth 

Medulla. 

c 

glossus. 

to  opposite 

truded  deviates  to 

nerve  (hy- 

side. 

paralyzed  side. 

poglossal). 

S  t  yloglos- 

Raises  tongue   Tongue  cannot  be 

The  twelfth 

Medulla. 

Bulbar  pal- 

sus. 

backward  and 

moved  backward 

nerve. 

sies     (acute 

upward. 

or   hollowed   out 
(action    deficient 
in  many  healthy 
subjects). 

and  chron- 
ic) ;  in   spe- 
cific and  tu- 
1    b  e  r  c  ulous 

Lingual 

All  movements 

When    lying    in 

The    twelfth 

Medulla. 

diseases    of 

muscle 

of  the  tongue 

mouth    deviation 

nerve. 

base  ;  d  y  s- 

proper. 

itself. 

to   healthy  side  ; 
when  protruded 
deviates  to  para- 
lyzed side;  if  one 
or  both  halves  are 

troph  ies 
(rare). 

atrophied  tongue 

looks  shrivelled. 

A  zy  go  s 

Shortening    of 

Uvula  deviates  to- 

Probably 

Medulla. 

A.s  above. 

uvulae. 

uvula. 

ward  sound  side  ; 
if  both  sides  are 
paralyzed     there 
are      nasal    tone 
and  regurgitation 

pharyngeal 
plexus; 
seventh 
nerve  (?). 

through  nose. 

__ 

DISEASES    OF   THE   SPINAL   CORD. 


223 


Muscles  op  Tongue,  Palate,  and  Pharynx. — Continued. 


Diseases  in 

Name  of 

Normal 

Symptoms  of  Defi- 

Innervated 

Represented 

which  Muscle  is 

Muscle. 

Function. 

cient  Action. 

by 

in 

commonly  In- 

volved. 

Levator 

Raises  the  ve- 

Arch   cannot    b  e 

As  above. 

Medulla. 

As  above  ;    s»-e 

palati. 

lum  palati. 

raised  in  the  in- 
tonation of  "'ah;" 
if  paralysis  is  bi- 
lateral flapping  of 
arch  and  regurgi- 
tation  of    food 
through  nose. 

a  1 s  o  seventh- 
nerve   aff ec 

tiollS. 

Palato- 

Prevent food 

Regurgitation    o  f 

The   fifth 

Pons. 

Basilar  affec- 

pharyn- 

from passing 

food;      nasal 

nerve. 

tions. 

geal  mus- 

toward up- 

speech. 

cles. 

per  part  of 
pharynx  and 
post  e  r i  o  r 
nares. 

Stylo- pha- 

Helps  to  draw 

Imperfect  degluti- 

Glosso -  pha- 

Medulla. 

Bulbar      affec- 

ryngeus. 

larynx    up- 

tion ;     food    gets 

ryngeal. 

tions  and  dis- 

ward so  as  to 

into  windpipe. 

eases    of    the 

be  closed  by 

base. 

epiglottis  and 

o  v  e  r  t  o  pped 

by  tongue. 

Cons  tric- 

Help  to   push 

Food  is  swallowed 

P  h  a  ryngeal 

Diseases  of  the 

tors    of 

food  into  gul- 

very imperfectly ; 

plexus. 

base  (bulbar). 

pharynx. 

let. 

sticks  in  throat. 

Laryngeal 

Movements  of 

Hoarseness    and  Recurrent 

Medulla 

Bulbar  trou- 

muscles. 

vocal  cords  in 

difficulty    in     laryngeal 

bles     (similar 

respiration 

breathing;  laryn- 

nerve ex- 

sympto m  s 

and  in  articu- 

goscopy examina- 

cepting the 

may  be  caused 

lation. 

tion  rsveals  false 

crico  -thy- 

by tumors  and 

position  of  vocal 

roid  m  u  s- 

foreign  bodies 

cords  (see  special 

cle. 

in  larynx). 

text-books). 

Muscles  <>k  Head  and  Xeck. 


Normal 
Function. 


Symptoms  of  Defi- 
cient Action. 


Raises  and 
turns  face  to 
opposite  side; 

head  inclines 
to  same  side; 
if  both  mus- 
cles act  con- 
jointly head 
is  brought 
forward. 


Inability-  to  raise 
head  from  bed,  or 
other  horizontal 
position,  if  both 
muscled  are  affect- 
ed; if  one  muscle 
i  s  affected,  n  o 
marked  change of 
position, .u  n  less 
opposite  muscle 
is  contractured  ; 
spasm  of  muscle 
frequent ;  head  in- 
clined to  one  side. 


Innervated 

by 


Spinal  ac- 
cessory. 


I     Diseases  in 
Represented  which  Muscle  is 
in  commonly  In- 

volved. 


Medulla  and 
second  and 
third  cer- 
vical    s  e  g' 

in. 'HIS. 


In  bulbar  and 
cervical  -cord 
affections  :  in 

later  st  • 

p  rog  i  e  b  give 
m  use  u 1  a  r 
at  roph  i  es  ; 
occasionally 
in  Deuritl8. 


224  DISEASES    OF   THE   NERVOUS    SYSTEM. 

Muscles  op  Head  and  Neck. — Continued. 


Diseases  in 

Name  of 

Normal 

Symptoms  of  Defi- 

Innervated 

Represented  which  Muscle  ia 

Muscle. 

Function. 

cient  Action. 

by 

in 

commonly  In- 
volved. 

Rec  t  xi  s 

To  flex  head. 

Cannot  flex  head  "1 

Upper  cervi- 

Upper   cer- 

capitis 

so   as   to  bring 

cal. 

vical    seg- 

anticus 

chin  on  chest. 

ments. 

major. 

Rectus 

To  flex  head. 

capitis 

anticus 

r 

minor. 

Diseases     o  f 
the  cervical 

Rectus 

Slight  rota- 

Deficient   rota- 

region  (my- 

capitis 

tion. 

tion     scarcely 

r  elitis,     meu- 

lateralis. 

noticeable,     un- 
less  sterno  clei- 
do-mastoids  are 
diseased. 

i  n  g  i  t  i  s  , 
tumor;  pro- 
gressive 
wasting    o  f 

Scaleni] 

Elevate  ribs- 

Deficient  inspi-"] 

Lower  cervi- 

Upper cervi- 

muscles). 

anterior 

when  verte- 

ratory   move- 

cal nerves. 

c  a  1    seg- 

medi- 

bral     column 

ments. 

ments. 

u  s,    e  t 

is  fixed  ;    aid 

poste- 

in   inspira- 

1 

rior,          r 

tion  ;  slight 
lateral     flex- 
ion. 

f 

Flexion  of  ver- 

Imperfect flexion 

Lower  cervi- 

. 

Lon  gus 

tebral     col- 

of upper  spine. 

cal  nerves. 

colli.       I 

umn. 

Muscles  of  Shoulders  and  Upper  Extremity. 


DISEASES    OF    THE    SPINAL   CORD.  225 

Muscles  of  Shouldep.s  and  Upper  .Extremity. — Continued. 


Name  of 
Muscle. 


Normal 
Function. 


3.  Lower 
portion 
and  ad- 
ductor. 


R  h  o  m  - 

boids. 


Levator 
a  n  g  u  1  i 
scapulas. 


Se  r  r  a  t  u  s 
magnus. 


Deltoid 
(three  « i  i  - 
visions,). 


InfraspiO 
natus.    ! 

Teres  [ 
minor.  J 

Subscap- 
ularis. 


Adduction  o  f 
scapula  to- 
ward median 
line. 


Oblique  move- 
ment of  scap- 
ula from  be- 
low, upward 
and  inward. 
so  that  infe- 
rior angle  is 
brought  near- 
er the  medi- 
an line;  hoi  i 
spinal  margin 
of  scapula 
down  to  tho- 
rax. 


Draws  superi- 
or inner  aujrle 
of  scapula  up 
w  a  r  d ;  aids 
iu  shrugging 
of  shoulders. 

Rotat  in  ii  of 
shoulder- 
blade  out- 
ward, and 
slight  eleva- 
tion of  acro- 
mion; holds 
inner  margin 
of  scapula  to 
thorax;brings 
arm  from  hor- 
izontal to  ver- 
tical position. 


To    raise    arm 
to  horizontal 

position,  and 
forward  out- 
ward.or  back- 
ward ;  move- 
ments possi- 
ble only  if 
sc  ap  ula  is 
fixed  by  ac- 
tion fit  serra- 
tus  and  tra- 
pezius, 

Ro  tat  fi  r  hu- 
meri posticus 
(  Duehenne  ) ; 
rot  ate  arm 
outward. 
Rotator  hume- 
ri a  n  t  i  e  u  s 
(  Duehenne) : 

rotates  arm 
inward 


Symptoms  of  Defi- 
cient Action. 


Innervated 

by 


Represented 


Margin  of  scapula  Spinal  acces- 

is  about  ten  cm.     sory  nerve. 

distant,  instead  of 

being  five  or  six 

cm.  distant  from 

median  line  ;  loss 

of  adductor  may 

be  covered  up  by 

action  o  f  rhom- 
boids ;    rounding 

of  back. 
Deep    groove    be-   Fifth    cervi- 

tween  inner  mar-     cal. 

gin  of  scapula  and 

thorax;   if  serra- 

tusis  normal,  this 

groove  disap- 
pears if  arm  is  ex- 
tended forward  ; 

shoulder  blade 

cannot  be  approx- 

imated  to  median 

line.    (According 

to  Duehenne  this 

can  be  effected  by 

upper  portion  of 

latissimus  dorsi.) 
Isolated   paralysis  Third    and 

rare.  fifth    cervi- 

cal nerves. 


Scapula  pulled  up-  Posterior 
wan  1 ;  lower  inner  thoracic 
angle  nearer  the  nerve. 
median  line;  arm 
caunot  be  raised 
above  horizontal 
position:  if  arm  i»- 
st  retched  forward 
scapula  is  re- 
moved from  tho- 
rax C  w  i  ng  -<l 
scapula"  );  dur- 
ing abduction  of 
arm,  scapula  i> 
moved  nearer  t< 
median  line,  and 
Crowds  trapezius 
and  rhomboids 
forward. 

Can  raise  shoulder  Circumflex, 
b  lit     not   a  r  m  ; 

shoulder  flattened 
(atrophy);  groove 

bet  ween  acromion 
and  head  of  hu- 
merus ;  each  di- 
vision fif  deltoid 
may  be  parah  zed 
Binglj . 


A  r  ni     cannot    be  S  u  p  r  a- 

moved  OUl  ward.  -capillar. 

Difficulty  iii   writ-  ( '  i  re  u  m- 

ing  t  Duehenne).  flex. 

Arm  cannot  be  Subscapu- 

iii  o  v  ed  inward  :  larnerve. 

scapula  is  rubbed 

against  ribs. 


Medulla  and 
second  and 
third  cervi- 
c  al  seg- 
ments. 


Fourth  an  d 
fifth  cervi- 
c  a  1  seg- 
ments. 


Second  and 
fourth  ( - 1 
cervical 

segments. 


Fifth  and 
sixth  cervi- 
c  a  1  seg- 
ments. 


Fourth,  fifth, 
and  sixth 
c-e  r  v  i  c  al 
segments. 


Fourth,  fifth, 
and  s  i  x t 1 1 
cervical 
segments. 


Diseases  in 
which  Muscle  is 
commonly  In- 
volved. 


As  above. 


Dystrophies 
and  cervical 
diseases. 


Progressive 
muscular  atro- 
phies ( d  y  s- 
trophies  :  neu- 
ritis of  part  of 
the  brachial 
plexus  ;  after 
traumatic  in- 
juries to  shoul- 
der :  in  cervi- 
cal-cord affec- 
tions. 


As  above  •  also 
in  Krb 

of    obstetrical 
parah 


As  in   case  Of 
deltoid. 


15 


226  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Muscles  of  Shoulders  and  Upper  Extremity. — Continued. 


Diseases  in 

.Name  of 

Normal 

Symptoms  of  Defi- 

Innervated 

Represented 

which  Muscle  is 

Muscle. 

Function. 

cient  Action. 

by 

in 

commonly  In- 
volved. 

Supras  p  i  - 

Helps       to 

According  to   Du- 

Suprascapu- 

Fourth   cer- 

As above. 

natus. 

steady  shoul- 
der-joint and 
to  elevate 
arm   forward 
and  outward ; 
outer  angle  of 
scapula  is  de- 
pressed. 

chenne,  humerus 
is  separated  still 
farther  from  acro- 
mion,    if   supra- 
spinatus  is  affect- 
ed in  addition  to 
deltoid. 

lar 

vical. 

Latissimus 

Pulls  the  arm 

Arm    cannot    b  e 

Subscapu- 

Sixth  and 

As  in  progres- 

dorsi. 

when    raised, 

moved  backward ; 

1  a  r,  also 

seventh  cer- 

sive atrophies 

downward 

insufficient  exten- 

branches  of 

vical. 

and    dystro- 

a n  d   b  a  e  k- 

sion    of    dorsal 

dorsal    and 

phies;  in  cer- 

ward;  if  arm 

spine;  trunk  can- 

lumbar 

vico-dorsal 

is  at  rest  up- 

not  be  moved  lat- 

nerves pass- 

lesions; in 

p  e  r    portion 

erally. 

ing  through 

neuritis. 

brings    scap- 

muscle. 

ula    nearer 

the    median 

line ;  united 

action  of  up- 

per   third  of 

both  muscles 

causes  exten- 

sion of  dorsal 

trunk  ;  single 

action  causes 

lateral  move- 

ment of  trunk. 

Teres  ma- 

Rotates raised 

Very    few    symp- 

Subscapular. 

Seventh  cer- 

As above. 

jor. 

humerus     in- 
ward; adduc- 
tion of  arm  to 
thorax;  slight 
elevation    o  f 
shoulder. 

toms;  action  sup- 
plied   b  y    other 
muscles. 

vical. 

Pectoralis 

Clavicular 

Imperfect   adduc- 

Anterior 

Fifth,  sixth, 

Amyotrophies 

major. 

portion     de- 

tion of  arm ;   pa- 

thoracic. 

and  seventh 

and    dystro- 

presses   hu- 

ralysis can  be  dis- 

cervical. 

phies,  chiefly; 

merus  from 

covered   best  by 

also  in  lesions 

raised    p  o  s  i- 

extending  arms 

of  brachial 

tion  to   hori- 

and   trying    t  o 

plexus. 

zontal  ;    ad- 

press  volar   sur- 

duction of 

faces     against 

arm,    as    in 

each  other. 

giving  a  bless- 

ing;    sternal 

portion    de- 

presses    arm 

completely, 

and  if  arm  is 

at  rest  draws 

acromion  for- 

w  a  r  d     and 

backward. 

DISEASES   OF   THE   SPINAL   CORD.  227 

Muscles  of  Arm,  Forearm,  and  Hand. 


Name  of 
Muscle. 


Normal 
Function. 


Symptoms  of  Defi- 
cient Action. 


Innervated 
by 


I     Diseases  in 
Represented  which  Muscle  is 
in  commonly  In- 

volved. 


Triceps . 


Biceps. 


Supinator 
longus. 


Supinator 

brevis. 


Extensor 
carpi  ra- 
d  i  a  1  i  s 
longus  et 
brevis. 


Extensor 
carpi  ul- 
naris. 


Extensor 
digit  o- 
rum  com- 
munis. 

Extensor 
Indicia. 

E  x  t  e  n  sor 
m  i  n  i in  i 
digit!. 

Flexor 
carpi 
radialis. 

Flexor 
carpi 
uln.'iris. 

Pal  maris 
longus. 


Extends  fore- 
arm; long 
head  of  tri- 
ceps, and  cor- 
aco-brachialis 
help  to  keep 
head  o  f  hu- 
merus in  posi- 
tion. 

Flexion  and 
supination  of 
forearm. 


Flexes  fore- 
arm and  aids 
in  pronation. 


Supinates 
hand  when 
forearm  is  ex- 
tended. 

Extension 
and  abduc- 
tion of  wrist ; 
the  shorter 
muscle  has 
pure  exten- 
s  i  o  n  action 
only. 

Extension  and 
abduction  of 
wrist. 


Extension  of 

fi  r  s  t  pha- 

r  langesofall 

fillers  and 

abduction. 

Flexion  of 
wrist  and  pro- 
nation. 

Flexion  of 
wrist  and 
supination. 

Flexion  of 
wrist  only. 


Arm  cannot  he  ex-  Musculo 
tended  except  by  |  spiral. 
its  own  weight;  if 
long  head  of  tri- 
ceps is  affected 
subluxation  o  f 
head  of  humerus 
occurs  easily. 


Flexion  deficient, 
but  can  be  carried 
out  in  part  by 
other  muscles. 


Flexion  and  prona- 
tion deficient: 
muscle  does  not 
stand  out  promi- 
nently if  arm  is 
flexed  and  a  t- 
tempt  is  made  by 
another  to  extend 
it  forcibly;  if  mus- 
cle is  atrophied 
arm  i  s  spindle- 
shaped. 

Deficient  supina- 
tion of  hand. 


Wrist  cannot  be 
flexed  dorsally 
(extended)  or  ab- 
ducted: flattening 
of  forearm. 


Wrist  cannot  be 
flexed  dorsally  or 
adducted;  "drop- 
wrist  "  is  charac- 
teristic of  paraly- 
sis of  extensors. 

First  phalanges 
cannot  be  ex- 
tended nor  Angers 
abducted  ;  grasp 
is  weak  because 
flexor  muscles  are 
shortened  a  n  d 
cannot  contract 
forcibly. 

Deficient  flexion. 


Musculo -cu- 
taneous. 


Musculo 

spiral. 


Musculo- 
spiral. 

Muse  ulo 
spiral. 


As  above. 


Musculo- 
spiral. 


Median  , 


Flexion  and   BUpi-  Ulnar, 
nation  impaired.     | 


Flexion  Impaired; 
no  anomul  0U8 
position  of  hand 
from  paralysis  of 
wrist  ashand  falls 
by  its  own  weight: 
the  flexors  0  f 
fingers  may  act  as 
substitutes. 


Median 


Sixth,  sev- 
enth, eighth 
cervical  seg- 
ments. 


Fourth,  fifth, 
sixth  cervi- 
cal. 


Fourth,  fifth 
cervical. 


Fifth    cervi- 
cal. 


Seventh  cer- 
vical. 


Seventh  cer- 
vical. 


Seventh  cer- 
vical. 


Eighth   cer- 
vical. 

Eighth   cer- 
vical. 

Eighth  cer- 
\  IcaL 


Poliomyelitis 
and  other 
affections  of 
cervical 
cord  ;  trau- 
matic inju- 
ries ;  amyo- 
trophies 
and  dystro- 
phies (tri- 
ceps es- 
capes in 
many  pe- 
ripheral 
palsies.) 
As  above  ;  in- 
volved in  pe- 
ripheral neu- 
ritis (traumat- 
ic), not  in 
lead  palsy. 


Diseases  as 
above ;  also 
i  n  peripheral 
palsies. 

As  before  ;  es- 
pe daily  in 
neuritis. 


As  above. 


As  above. 


As  above. 
As  above. 
As  above. 


228  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Muscles  of  Arm,  Forearm,  and  Hand. — Continued. 


Diseases  in 

Name  of 

Normal 

Symptoms  of  De- 

Innervated 

Represented 

which  Muscle  is 

Muscle. 

Function. 

ficient  Action. 

by 

in 

commonly  In- 
volved. 

Flexor 

Flexes  second 

Second  phalanx 

Eighth  cer- 

As above. 

d  i  g  i  to- 

phalanx    to- 

cannot be  flexed. 

vical. 

rum    sub- 

ward  first. 

limis. 

Flexor 

Flexes     last 

Last  two  phalanges 

Ulnar    and 

Eighth  cer- 

As    above; 

d  i  g  i  to- 

two  phalanges 

cannot  be  flexed. 

Median. 

vical. 

muscle  should 

rum    pro- 

toward first. 

be  tested  with 

fundus. 

special  care 
i  n    cases    o  f 
traumatic    in- 

Interossei 

Abduction  and 

Fingers  cannot  be 

Ulnar,  which 

Eighth  cer- 

juries. 
As  above ;  oft- 

and  lura- 

adduction   of 

abducted   or   ad- 

also   sup- 

vical,    first 

en    the   fi  r  s  t 

bricales. 

fingers  if  first 

ducted  ;    inter- 

plies    third 

dorsal. 

muscles  to  be 

phalanges  are 

osseous  spaces 

and    fourth 

affected   in 

extended; 

are  very  marked ; 

lumbri- 

p  r  o  g  r  e  s  sive 

flexion  of  first 

"Main  en  griff e  " 

cales ;  medi- 

spinal  atro- 

p h  alaug  es 

due  to  extension 

an  supplies 

phies. 

and  simul- 

of first  phalanges 

first  two  and 

taneous    ex- 

and  flexion    o  f 

so  m  e  times 

tension  of  sec- 

second and  third 

third    lum- 

ond  and  third 
phalanges. 
Extends     first 

phalanges. 

bricales. 

Thenar 

Impairment  of  ex- 

M us  en  lo- 

First  dorsal. 

As  before; 

muscles  : 

phalanx    and 

tension    and    ad- 

spiral. 

more  espe- 

Extensor 

abducts  meta- 

duction ;    flatten- 

cially in  amyo- 

pollicis 
brevis. 

carpal   bone  ; 

ing   of   ball    of 

trophies  and 

acts  -with  ad- 

thumb. 

neuritis. 

ductor    polli- 

cis longus. 

Extensor 

Extends    both 

Deficient  extension 

Musculo- 

First  dorsal. 

As  above. 

pollicis 
longus. 

phalanges   of 

and   adduction  ; 

spiraL 

thumb  ;    also 

second  phalanx  is 

adduction    of 

flexed    toward 

metacarpal 

first. 

bone     and 

backward 

movement  of 
thumb. 
Abduction     of 

A  b  d  uotor 

Deficient  abduc- 

Musculo- 

First  dorsal. 

As  above. 

pollicis 
longus. 

metaca  rpal 

tion   of  metacar- 

spiral. 

bone  ;  aids  in 

pal  bone  ;  if  this 

flexion  of 

muscle   and    ex- 

hand. 

tensor  pollicis 
brevis  are  par- 
alyzed adduction 
results. 

Abductor 

Musculo- 

pollicis 
brevis. 

spiral. 

Opponens 
pollicis 
and  outer 

O  p  p  o  s  ition 
of  thumb. 

No  opposition 
movement. 

Median. 

First  dorsal. 

As  above. 

portion  of 

the  flexor 

brevis. 

1 

Abductor 

Flex  first  pha- 

No flexion;  if  mus- 

Median   and 

As  above. 

pollicis 
brevis; 

lanx  and   ex- 

cles are  paralyzed 

ulnar. 

tend  second 

a  n  d     atrophied. 

flex  o  r 

phalanx  (like 

ape   hand    is 

brevis  and 

i  n  terns  sei ), 

formed. 

adductor. 

also  have  an 
abduction 
and  adduc- 
tion action. 

Flexor 

Flexes  end 

No  flexion  of  end 

Median. 

As  above. 

pollic  is 
longus. 

phalanx. 

phalanx. 

t 

DISEASES    OF   THE    SPIXAL   CORD.  229 

Muscles  of  Back  and  Lcayeb.  Extremities. 


Name  of  Muscle. 


Innervated  by 


Erector  spinae;  sa- 
cro-lumbalis:  lon- 
gissimus  dorsi. 

Abdominal  muscles. 


Quadratus     lumbo- 

IUI11. 

Adductor  muscles. 
Sartorius. 
Quadriceps  femoris. 

Ilio-psoas. 

Tensor  fasciae  latae. 

External  rotators:  ] 
Pyrif  ormis . 
Gemeili. 

Quadratus  femoris.  J  | 
Internal  obturator.  I 
External  obturator  | 

Gluteal  muscles. 

Biceps  ;  semitendi- 
iimsus  and  semi- 
membranosus. 

Gastrocnemius  (al- 
so plantarius  and 
soleus). 

Anterior  tibial  mus- 
cles (tibialis  ami- 
cus, extensor  digi- 
toruui,  and  exten- 
sor  poliicis  lon- 
gus). 

Peroneus  longus. 


Posterior  tibial  mus- 
cle. 

Peroneus  brevis. 

I  n  terossei  pedis  et 
lmnbricales. 

Adductor  :  flexor 
brevis  and  abduc- 
tor ballucis. 


Dorsal  nerves.  Second  to 
twelfth  dorsal  segments. 


Dorsal  nerves.  Second  to 
twelfth  dorsal. 


Lumbar  nerves. 

Obturator  nerve,  great 
sciatic  and  crural. 

Crural.  Third  lumbar 
segment. 

Crural.     Third  lumbar. 


Crural  (lumbar  plexus). 

Fourth  lumbar. 
Superior  gluteal.  Fourth 

lumbar. 

Sacral  plexus  (muscular 
branches).  Fifth  lum- 
bar. 

Obturator    nerve    (lum- 
bar plexus). 
Inferior  gluteal  (sacral 
plexus  i.  First  aud  sec- 
ond sacral. 
Gluteal  superior.    First 
I     and  second  sacral. 
Sciatic.    Fifth  lumbar 
segment. 


Internal  popliteal.    Fifth 
1  tun  bar. 

Anterior  tibial.     Fifth 
lumbar  and  first  sacral. 


Peroneal.  First  and  sec- 
ond   sacral    segments. 

Posterior    tibial     nerve. 

First  and  second  seg- 
ments. 

Peroneal.  First  and  sec- 
ond segments. 

Posterior  tibial.  First 
and  second  segments. 

Posterior'  tibial.  First 
and  second  segments. 


Symptoms  of  Deficient  Action. 


Loi-dosis  of  lower  spine;  perpendicular 
line  from  shoulder  falls  behind  os  sa- 
crum ;  unilateral  palsy  causes  deflection 
of  spine  toward  sound  side. 

Lordosis  witli  protrusion  of  nates  and 
abdomen:  other  actions  deficient ;  can- 
not straighten  up  from  recumbent 
position  without  assistance  of  hands. 

Lateral  movements  of  lower  vertebras 
imperfect. 

No  adduction;  thigh  rolls  outward. 

Flexion  impaired;  acts  imperfectly. 

Leg  cannot  be  extended;  to  test  it  ask 
patient,  who  is  lying  down  with  hip 
bent,  to  stretch  out  the  leg:  when  pa- 
tient is  sitting  down  to  extend  leg. 

I  Flexion  difficult;  in  bed  thigh  cannot  be 
flexed:  difficulty  rising  from  horizon- 
tal position. 

Deficient  outward  rotation  ;   leg  turned 

inward. 


No  extension  of  thigh:  great  difficulty  in 
climbing;  no  abduction  of  thigh;  wad- 
dling gait,  exaggerated  movement  of 
pelvis. 

Deficient  flexion;  action  of  cjuadriceps 
may  cause  excessive  extension;  in 
standing  thigh  is  flexed  to  excess; 
trunk  moved  backward. 

Deficient  flexion  of  foot  ;  heel  cannot  be 
raised  ;  cannot  stand  on  tiptoes. 

Deficient  extension;  "* dnopfoot,"  toes 
scrape  floor;  to  clear  this,  excessive. 
flexion  at  knee  and  hip  ;  coni  nidi  ire  .if 
flexors  aud  pes  equinus  or  equino varus, 


Deficient  abduction  ;  plantar  arch  les- 
sened; increased  by  contracture.  Flat- 
foot  ;  walking  tiresome. 

Ivlioieiit    abduction   or   adductiou  ;    ,lo- 
[     fortuities  result  from  deficiencies. 

Mi.luetion  and  adduction  of  toes  defi- 
cient ;  paralysis  of  Interossei;  hyperex- 
tensioii  of  first  phalanges;  second  and 
third  flexed  wlawed  foot  '. 

Deficient  flexion  of  t ;  foot  cannot  be 

pushed  oil  ground  easily. 


The  blood  supply  of  the  spinal  cobd  is  a  subject  of  great 
practical  importance;  and,  as  oxer  knowledge  of  it  has  lately  been 
inn-eased,  I  shall  present  the  matter  here  in  some  detail. 

The  spinal  cord  is  supplied  with  blood  by  branches  from  the 
vertebral,  ascending  cervical,  and  superior  intercostal  arteries 
above,  and  by  the  dorsal  intercostal,  lumbar,  and  sacral  arteries 
below.      These  send  off  small  branches  which  enter  the  spina]  tana] 


230 


DISEASES    OF   THE    NEKVOUS    SYSTEM. 


through  the  foramen  magnum  above  and  the  intervertebral  fora- 
mina at  the  sides;  they  pierce  the  dura  mater  and  are  distributed 
on  the  pia  mater  and  in  the  cord.  The  arteries  that  thus  supply 
the  cord  are  these : 


Primary  Arteries. 


Anterior  spinal. 
Posterior  spinal. 
Lateral  spinal. 
Lateral  spinal. 

Lateral  spinal. 

Lateral  spinal. 

Lateral  spinal. 


Origin  from 


Vertebral  (from  subclav.). 

Vertebral. 

Vertebral. 

Ascending  cervical  (from  sub- 
clav.). 

Superior  intercostal  (from  sub- 
clav.). 

Thoracic  intercostal  (from 
aorta). 

Lumbar  (aorta). 

Lateral  sacral  (from   int.  iliac). 


Ending  in 


Anterior  median  spinal  artery. 


Anterior   and    posterior   spinal 

root  arteries 
Anterior   and    posterior   spinal 

root  arteries. 
Anterior   and   posterior    spinal 

root  arteries. 
Anterior   and    posterior   spinal 

root  arteries. 


The  anterior  spinal  arteries  are  branches  of  the  vertebrals. 
They  unite  to  form  the  anterior  median  artery,  which  runs  down 
the  whole  length  of  the  cord,  receiving  re-enforcements  from  the 
lateral  arteries  (Fig.  112).  The  anterior  spinal  arteries  themselves 
nourish  only  a  few  upper  segments  of  the  cord.  The  anterior 
median  artery  is  not,  as  has  been  taught,  a  true  prolongation  of  the 
anterior  spinals,  but  is  really  made  up  by  the  lateral  spinals.  In 
other  words,  the  vertebral  artery  through  its  branches  nourishes 
only  the  upper  cervical  region  of  the  cord.  The  posterior  spinal 
arteries  are  smaller  than  the  anterior  and  unite  on  the  posterior 
surface  of  the  cord.  They  do  not  continue  down  as  a  posterior 
median  artery — there  is  no  such  artery ;  but  they  help  to  form  two 
plexuses  on  the  postero-lateral  surfaces  of  the  cord. 

The  lateral  spnnal  arteries  are  derived  from  branches  of  the  sub- 
clavian artery  as  far  down  as  the  second  dorsal  root;  below  this 
point  by  the  thoracic  and  abdominal  aorta  and  the  internal  iliac. 
It  is  an  interesting  fact  that  at  or  a  little  below  the  point  where  the 
blood  supply  changes  from  the  subclavian  above  the  heart  to  the 
aorta  below,  pathological  disturbances  frequently  occur  (transverse 
myelitis). 

Root  Arteries. — The  lateral  spinal  arteries,  after  they  enter  the 
spinal  canal,  are  called  the  root  arteries.  They  pierce  the  dura 
mater  and  pass,  some  along  the  posterior  and  some  along  the  an- 
terior roots,  to  the  cord.  There  are  about  eight  anterior-root 
arteries  (five  to  ten)  and  about  sixteen  posterior-root  arteries  (see 
Tigs.  112,  113).  The  anterior  arteries  are  twice  as  large  (one  milli- 
metre in  diameter)  and  one-half  as  numerous  as  the  posterior.  The 
root  arteries  of  the  cervical  region  are  rather  the  more  numerous. 
There  is  a  large  and  constant  anterior-root  artery  in  the  dorso- 
lumbar  region.  The  last  two  lumbar,  the  five  sacral  nerves,  and 
the  unpaired  coccygeal  nerve  when  it  exists,  are  accompanied  by 
small  root  arteries  which  do  not  reach  up  to  the  cord  itself.  The 
lower  part  of  the  spinal  cord  is  supplied  by  large  root  arteries  from 


DISEASES    OF   THE    SPINAL   CORD. 


231 


the  lateral  spinal  arteries.  Hence  the  theory  of  Moxon  that  the 
circulation  here  is  feeble  is  not  supported  by  Kadyi's  investiga- 
tions. 


^> 


FIG.  112.— The  Spinal  Cord,  Anterior  Surface,  showing  the  nerve  roots,  root  arteries., 
and  anterior  plexus  (Kudyi). 


232 


DISEASES    OF  THE    NERVOUS    SYSTEM. 


The  Plexuses. — The  anterior  root  arteries  pass  to  the  anterior 
median  fissure,  and  then  divide,  partly  to  form  the  anterior  median 
artery  and  partly  to  form  a  rich  plexus  between  the  anterior  roots ; 
this  is  called  the  anterior  arterial  plexus.  The  posterior  root  arte- 
ries subdivide  before  they  reach  the  cord,  and  send  twigs  to  its  lat- 
eral and  posterior  surfaces  which  form  the  gostercylateral  arterial 
plexus.  The  posterior-root  arteries  do  not  anastomose  to  any  ex- 
tent with  each  other  or  form  a  posterior  spinal  artery,  as  is  done  by 
the  anterior-root  arteries.  There  are  therefore  three  relatively  in- 
dependent arterial  plexuses:  the  anterior  plexus,  the  two  postero- 
lateral plexuses. 

Veins. — The  veins  of  the  spinal  canal  outside  the  dura  mater 
have  valves,  those  within  it  have  none.  The  veins  reach  the  pia 
mater  and  cord  by  passing  along  the  nerve  roots.  Hence  we  have 
anterior  and  posterior  root  veins,  corresponding  to  the  root  arteries, 
but  more  numerous,  there  being  a  total  of  forty  or  fifty.     The  an- 


=-# 


Fig.   113.— The  Arterial  Supply.     A,  The  artery  of  the  posterior  Assure;   B,  the  inter- 
funicular;  C,  artery  of  posterior  horn  ;  D.  of  posterior  root;  E,  of  posterolateral  column. 


terior-root  veins  are  more  numerous  than  the  posterior,  but  smaller 
(twenty -five  to  twenty).  The  veins  are  a  little  larger  than  the 
arteries,  the  anterior  veins  being  one-half  to  one  millimetre,  the 
posterior  one  and  one-half  to  two  millimetres,  in  diameter. 

Thus  we  see  that  the  posterior  surface  of  the  cord  has  more  and 
smaller  arteries,  fewer  but  larger  veins.  The  posterior  surface  is 
on  the  whole  more  richly  supplied  with  veins,  the  anterior  surface 
with  arteries.     The  lateral  surfaces  are  the  least  vascular. 


DISEASES   OF   THE    SPIXAL   CORD.  233 


Anterior  root  arteries. 
Anterior  root  veins. . . 
Posterior  root  arteries 
Posterior  root  veins. . . 


Number. 

Size. 

5  to  10 

1    mm. 

25  to  30 

.V  to  1    mm. 

16 

4-  mm. 

20  to  25 

1£  to  2    mm. 

Vessels  of  the  Cord  Substance. — The  cord  is  suppplied  by  (1) 
central  arteries  which  are  branches  of  the  anterior  median,  and  by 
(2)  peripheral  arteries  which  come  from  the  plexuses  on  the  pia 
mater.  These  two  systems  have  been  called  also  the  centrifugal 
and  centripetal  respectively.  They  are  not  absolutely  independent, 
but  are  in  a  good  measure  so.  The  central  arteries  nourish  chiefly 
the  gray  matter,  the  peripheral  arteries  the  white.  Both  systems 
are  made  up  of  "  end  arteries,"  i.e.,  they  do  not  anastomose  with  each 
other.  Neither  the  central  nor  the  peripheral  arteries  are  dis- 
tributed in  accordance  with  anatomical  relations  or  physiological 
functions.  Each  cell  group,  for  example,  lias  a  vascular  supply 
from  several  sources. 

The  central  arteries  are  given  off  from  the  branches  of  the  an- 
terior median  at  the  bottom  of  the  median  fissure  and  number 
about  two  hundred,  each  spinal  segment  having  six  or  seven.  The 
accompanying  central  veins  are  small  and  their  total  capacity  is  less 
than  that  of  the  arteries,  so  that  the  central  arterial  pressure  must 
be  high,  on  account  of  the  poor  venous  outlet  (Kadyi).  Some  of 
the  blood  escapes  by  the  peripheral  veins. 

The  peripheral  arteries  pass  into  the  spinal  cord  for  the  most 
part  along  the  various  connective-tissue  septa.  There  they  branch 
and  supply  chiefly  the  white  matter.  They  supply  the  apex  and 
some  of  the  deeper  substance  of  the  posterior  horns  and  Clark's 
columns.  The  arteries  of  the  posterior  septum  are  the  largest  and 
most  numerous,  often  reaching  to  the  gray  commissure.  The 
peripheral  arteries  are  smaller  than  the  corresponding  veins  (0.04  to 
0.2  nun.).  The  relation  is  just  the  reverse,  therefore,  of  that  of  the 
central  arteries  and  veins.  The  peripheral  arteries  are  small,  and 
after  passing  into  the  cord  branch  into  minute  vessels  which  pass 
up  ami  down  and  soon  become  capillaries.  The  central  arte 
on  the  other  hand,  continue  large,  and  run  up  and  down  some  dis- 
tance before  they  are  subdivided  into  capillaries. 

To  sum  up:  The  arteries  predominate  in  total  capacity  in  the 
anterior  plexus  and  central  arteries;  the  veins  in  the  posterior 
plexuses  and  peripheral  vessels.  The  central  arteries  are  larger  and 
er  than  the  peripheral.  Hence  the  blood  circulates  more 
quickly  and  under  greater  pressure  in  the  central  gray  of  the  cord. 
Conditions  of  enfeebled  circulation  would  affect  the  posterior  col- 
umns and  roots  more  than  the  anterior  and  central  parts  of  the 
cord. 


CHAPTER   XII. 

THE- DISEASES   OF   THE    SPINAL   COED. 

There  are  about  thirty  diseases  which  may  be  classified  as  be- 
longing to  the  spinal  cord.  Most  of  these  are  organic  in  character 
and  come  under  the  head  of  inflammatory  and  degenerative  or  sys- 
tem diseases.  Functional  disorders  referable  to  the  cord  alone  are 
rare ;  while  of  organic  diseases,  those  that  result  from  injury  and 
inflammation  are  the  most  common. 

Etiology. — The  causes  of  spinal-cord  diseases  can  nearly  all  be 
formulated  under  the  heads  of  injury,  exposure,  poisons,  autotox- 
semias,  infections,  and  excessive  functioning.  Persons  of  middle 
life  are  the  most  predisposed,  while  heredity  does  not  play  an  im- 
portant part. 

Symptoms. — The  symptoms  of  all  disorders  of  the  nervous  cen- 
tres can  be  included  under  the  heads  of  those  of  irritation,  depres- 
sion, and  perversion.  The  principal  irritative  symptoms  in  spinal- 
cord  disease  are  pains  and  parsesthesias  of  the  back  and  limbs, 
hyperaesthesia  and  feelings  of  constriction  around  the  waist,  rigidity, 
spasms,  exaggerated  reflexes,  and  irritability  of  the  visceral  and 
vascular  functions.  The  principal  symptoms  of  depression  and 
destruction  are  anaesthesia,  ataxia,  paralysis,  wasting,  and  loss  of 
power  over  visceral  centres.  The  common  form  of  paralysis  in 
spinal-cord  disease  is  paraplegia,  in  brain  disease  hemiplegia,  in 
multiple  neuritis  quadruplegia.  Symptoms  of  irritation  and  de- 
pression often  accompany  each  other.  The  more  superficial  and 
meningeal  the  disease,  the  more  are  the  symptoms  irritative;  the 
more  central  and  myelonic  the  trouble,  the  less  the  irritation  and 
the  more  the  paralysis  and  visceral  disturbance.  Thus  meningitis, 
meningeal  tumors,  and  hemorrhages  are  extremely  painful;  while 
central  myelitis  is  almost  painless. 

Pathology. — Inflammations  of  the  meninges  of  the  cord  are  not 
rare;  the  opposite  is  true  of  primary  inflammations  of  the  cord 
itself.  As  will  be  shown  later,  most  of  the  diseases  that  used  to 
be  called  chronic  myelitis  are  secondary  to  injuries  and  softenings. 
Degenerative  diseases  of  the  cord,  which  include  such  affections  as 
locomotor  ataxia  and  progressive  muscular  atrophy,  used  to  be  called 


THE    DISEASES   OF   THE    SPINAL   COED.  235 

"system  diseases,"  because  they  affected  certain  Jong-fibre  tracts  or 
systems  of  cell  groups.  The  name  implies  restrictions  which  are 
not  justified  in  fact,  and  it  can  be  retained  only  as  a  matter  of 
convenience.  Secondary  degenerations  alone  are  always  systemic. 
The  cord  is  relatively  free  from  abscesses,  hemorrhages,  and  tumors. 

Diagnosis. — In  making  a  diagnosis  of  spinal-cord  diseases,  one 
is  most  helped  by  a  thorough  knowledge  of  the  cord  functions.  In 
no  part  of  the  economy  do  physiology  and  anatomy  point  out  more 
clearly  the  path  to  the  clinician. 

Prognosis. — The  spinal-cord  tissue  once  destroyed  can  never  be 
renewed,  or  only  to  a  limited  extent,  and  that  as  regards  the  nerve 
fibres,  not  the  cells.  It  has  considerable  power  of  adjusting  itself 
to  damage;  but,  on  the  other  hand,  serious  injury  is  likely  to  extend 
by  the  process  of  secondary  degeneration.  Functional  diseases, 
vascular  and  nutritive  disturbances,  of  the  cord  can  never  be  so 
severe  or  chronic  as  to  exclude  the  possibility  of  recovery. 

The  special  diseases  of  the  spinal  cord  are  the  following : 

1.  Malformations :  Myelocele,  meningo-myelocele  (spina  bifida), 
meningocele,  heteropia,  amyelia,  micromyelia,  macromyelia,  double 
cord. 

2.  Vascular  Disorders :  Anaemia,  hypersernia,  hemorrhage,  end- 
arteritis with  aneurism,  embolism  or  thrombosis,  oedema.  Second- 
ary to  these  conditions  are  softenings  and  sclerosis. 

3.  Inflammations:  Meningitis,  myelitis,  abscess.  Secondarily, 
softenings,  sclerosis. 

4.  Degenerations :  Primary  :  locomotor  ataxia,  combined  sclero- 
ses, hereditary  scleroses,  progressive  muscular  atrophy,  and  allied 
types. 

5.  Tuberculosis :  Miliary  and  solitary. 

6.  Syphilis:  Gumma,  meningo-myelitis,  vascular  disease. 

7.  Tumors. 

8.  Functional  and  toxic  disorders. 


MALFORMATIONS. 
Spina  Bifida  (Rhachisi  bisis   Posterior). 

Spina  bifida  is  a  congenital  hernia  of  the  spinal  membranes,  and 
sometimes  of  the  cord,  through  a  cleft  in  the  vertebra  caused  by 
absence  of  the  vertebral  arches.  It  is  really  a  malformation  of  the 
vertebral  canal  rather  than  of  the  cord. 

Etiology. — The  condition  is  not  very  rare,  about  1  child  in  1,200 
(French  statistics)  being  affected.     It  is  often  associated  with  hy- 


236 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


drocephahis  or  with,  some  otlier  defect  in  development,  such,  as 
ventral  hernia,  imperforate  anus  or  pharynx.  Hereditary  influence 
is  sometimes  a  factor.  It  is  a  true  developmental  defect,  and  is  not 
due  to  a  primary  dropsy  of  the  cord,  as  was  once  taught.  It  occurs 
rather  oftener  in  females. 

Forms.  —  There  are  three  varieties  described : 

1.  Spinal  meningocele  is  a  condition  in  which  the  spinal  mem- 
branes alone  protrude  into  the  sac. 

2.  Spinal  meningo-myelocele  is  a  form  in  which  the  membranes 
and  cord  both  protrude. 

3.  Syringo-myelocele  (hydrorrhachis  interna)  is  a  form  in  which 
the  fluid  is  in  the  central  spinal  canal,  and  the  inner  lining  of  the 
sac  is  formed  by  the  meninges  and  thinned-out  spinal  cord. 


o  bca 


a  bca 


Fjg.  114.— Meningocele. 


I 

a       a  a      a 

Meningomyelocele.        Syringo-Mtelocele.       a,  Vertebral 
walls;  b,  cord;  c,  membranes. 


Anatomy. — The  first  two  forms  are  the  most  common  and  are 
called  hydrorrhachis  externa.  The  fluid  here  lies  in  the  subarach- 
noid sac,  and  hence  the  wall  of  the  protruding  cyst  is  lined  with  the 
dura  and  arachnoid.  The  nerves  and  cord  protrude  into  the  sac  in 
two-thirds  of  the  cases  (forming  a  meningo-myelocele),  but  in  some 
of  these  only  a  few  nerves  are  found.  These  structures,  when  pres- 
ent in  the  sac,  as  in  meningo-myelocele,  lie  on  its  posterior  and 
median  surface.  They  are  attached  to  and  form  part  of  the  wall. 
The  spinal  nerves  therefore  start  from  the  wall  of  the  sac  and  go 
back  into  the  vertebral  canal.  The  tumor  contains  cerebro-spinal 
fluid,  and  occasionally  connective  tissue  and  fat  (Fig.  114).  The 
external  surface  is  often  red  and  smooth,  and  there  is  sometimes  a 
depression  on  its  median  surface  where  the  cord  is  attached. 

Symptoms. — Spinal  bifida  occurs  almost  always  in  the  lumbar 
and  sacral  region,  the  reason  being  that  the  laminae  here  are  the 
last  to  solidify.     Usually  but  two  or  three  vertebras  are  involved. 


THE    DISEASES    OF   THE    SPIXAL   CORD. 


237 


The  tumor  varies  in  size  from  3  cm.  (one  inch)  to  15  cm.  (six 
inches)  in  diameter,  and  may  have  a  bioad  base  or  be  pedunculated. 
The  outer  skin  is  often  glossy,  or  tough,  thickened,  or  ulcerated 
(Fig.  115). 

'Children  with  spina  bifida  are  usually  feeble,  badly  nourished, 
and  poorly  developed  mentally.  Paraplegia  occurs  in  half  the 
cases,  sometimes  with  anaesthesia  a  ad  involvement  of  the  sphinc- 
ters.    Talipes  occurs  quite  often. 

The  prognosis  is  grave.  Most  subjects  die  unless  treatment  is 
applied,  and  even  then  the  prospect  is  not  very  good.  The  prognosis 
is  best  for  meningocele. 

The  diagnosis  is  easy.  It  is  generally 
only  necessary  to  exclude  congenital 
tumors  which  happen  to  be  located  in  the 
lumbo-sacral  region.  The  mo.t  import- 
ant question  to  decide  is  whether  the  cord 
and  nerves  are  present  in  the  sac.  This 
may  be  assumed  as  probable  if  there  is 
much  paraplegia,  anaesthesia,  and  sphinc- 
ter trouble,  and  if  there  is  a  depression  on 
the  median  external  surface.  The  intro- 
duction of  an  insulated  needle  connected 
with  an  electric  battery  may  be  tried. 

The  IreabmemSb  is  strictly  surgical,  and 
then  is  of  avail  only  in  meningocele.  At 
present,  injections  of  Morton's  fluid 
(iodine,  gr.  x. ;  potas.  iodid.,  gr.  xxx.  ; 
glycerin,  \  i.  Dose,  3  i.)  seem  to  be 
most  successful.  These  injections  should  be  made  in  the  lai •  i;d 
portion  of  the  sac,  and  the  child  should  be  kept  on  the  back. 
Puncture  and  withdrawal  of  fluid  Avith  compression  is  not  a  justifia- 
ble operation.  Ligaturing  or  opening  and  excising  of  the  sac  are 
dangerous,  especially  if,  as  is  often  the  case,  part  of  the  cord  and 
nerves  lie  in  the  sac  In  recent  years,  surgical  results  have  been 
more  favorable  and  warrant  serious  consideration.  No  surgical 
treatment  should  be  attempted,  however,  until  two  or  three  months 
after  birth. 

Hetekopi  v  is  a  rare  malformation  in  which  masses  of  gray  mat- 
ter are  found  in  abnormal  situations.  A  false  heteropia  may  be 
Caused  (Van  (neson)  by  manipulation  of  the  cord  in  its  removal 
after  death.  The  displaced  masses  consisl  of  nerve  cells  or  neu- 
roglia. 

Amtell*  or  absence  of  the  spinal  cord  can  exist  only  when  the 
brain  is  absent;  but  absence  of  the  brain  may  occur  without  absence 


Fiq.  115. -Spina  Bifida. 


238  DISEASES   OF   THE    NERVOUS   SYSTEM. 

of  the  cord.  In  amyelia  the  spinal  nerves  are  usually  present. 
Amyelic  monsters  cannot  live. 

Double  Cokd  is  a  very  rare  defect  and  involves  only  part  of  the 
cord  except  in  cases  in  which  there  is  a  double  vertebral  canal. 

Double  central  canal  is  not  rare.  It  usually  involves  only  a 
part  of  the  cord.     The  two  canals  are  side  by  side. 

Asymmetry  of  the  cord,  usually  due  to  abnormality  in  the 
course  of  the  pyramidal  tracts,  is  not  extremely  rare. 

Splitting  of  the  cord  and  defects  in  development  at  special 
levels  are  occasionally  observed. 

Micromyelia  is  a  condition  in  which  the  spinal  cord  is  abnor- 
mally short  or  small  in  size,  and  is  not  a  very  rare  anomaly.  The 
normal  adult  cord  has  a  diameter  in  its  various  parts  of  6  to  9  mm. 
(dorsal),  8  to  11  mm.  (upper  cervical),  15  mm.  (cervical  swelling), 
and  12  mm.  (lumbar). 

SPINAL  HEMORRHAGE   (SPINAL  APOPLEXY). 

This  general  name  may  be  given  to  (1)  spinal  meningeal  hem- 
orrhage or  hsematorrhachis,  and  (2)  hemorrhage  into  the  cord 
substance,  or  hsematomyelia. 

1.  Spinal  meningeal  hemorrhage  is  far  the  most  common 
form.  It  may  be  outside  or  inside  of  the  dura,  the  former  being 
rather  oftener  seen. 

Etiology. — It  occurs  in  newly  born  children  and  in  adults,  and 
is  more  common  in  men  than  in  women.  Injuries,  falls,  fractures 
of  the  spine  are  the  most  frequent  exciting  causes.  Severe  convul- 
sions from  epilepsy,  eclampsia,  tetanus,  chorea,  or  strychnine  may 
be  a  cause,  also  severe  muscular  exertion.  Purpura  and  the  blood 
states  following  malignant  infectious  fevers,  bursting  of  an  aortic 
or  vertebral  aneurism,  and  cerebro-spinal  meningitis  are  rare  causes. 

Symptoms. — In  small  hemorrhages  there  may  be  no  symptoms. 
In  large  effusions  there  are  sudden,  very  severe  pains  in  the  back, 
extending  into  the  limbs,  numbness,  tingling,  hypersesthesia,  and 
muscular  spasm,  especially  of  the  back  muscles.  Later  there  may 
be  weakness  or  paralysis  and  anaesthesia,  with  disorder  of  the  vis- 
ceral centres.  The  symptoms  reach  their  height  usually  in  a  few 
hours.  Then  amelioration  may  occur,  followed  by  slow  recovery 
or  with  symptoms  of  chronic  meningitis.  llarely  death  occurs 
early  from  exhaustion. 

Diagnosis. — A  history  of  injury  or  childbirth,  sudden  onset  of 
attack,  with  symptoms  of  pain  and  irritation  which  rather  rapidly 
subside,  point  to  extradural  hemorrhage.  In  hfematomyelia  there 
are  less  pain  and  irritation,  but  more  profound  paralysis  and  anaes- 
thesia.    The  same  is  true  of  crush  of  the  cord  from  fracture  or  dis- 


THE    DISEASES   OF   THE    SPINAL    CORD.  239 

location.  In  tetanus  there  is  a  slower  development  of  the  symp- 
toms, and  trismus  is  present. 

The  prognosis  is  grave  in  severe  cases,  but  if  the  patient  survives 
three  or  four  days  the  prospect  of  partial  or  nearly  complete  recov- 
ery is  good. 

The  treatment  is  perfect  rest  in  bed  and  the  administration  of 
remedies  to  move  the  bowels  and  relieve  pain;  leeches  and  other 
local  applications  are  of  doubtful  value.  It  is  of  no  use  to  give 
styptics  except  in  purpura,  when  mineral  acids  or  suprarenal  ex- 
tract may  be  tried.  Later,  one  may  give  iodide  and  mercury  and 
use  blisters  to  the  back. 

2.  Hemorrhage  into  the  Substance  of  the  Cord  (H.emato- 
myelia) — Etiology. — The  condition  is  not  very  rare.  It  may  be 
primary  from  disease  of  the  blood-vessels  or  purpura  haemorrhagica ; 
or  it  may  be  secondary  to  myelitis  and  tumors.  Primary  hemor- 
rhage occurs  sometimes  in  infancy,  but  usually  in  males  between 
the  twentieth  and  fortieth  year.  Injuries,  overexertion,  exposure, 
excessive  coitus  (Gowers),  syphilitic  disease  of  the  blood-vessels, 
and  convulsions  are  causes.  The  disease  sometimes  occurs  in  old 
people  with  degenerated  arteries,  which  break  and  lead  to  a  spinal 
apoplexy,  just  as  occurs  in  the  brain. 

The  symptoms  develop  rapidly,  with  at  first  feelings  of  numb- 
ness or  weakness  for  one  or  two  hours  or  longer.  Then  there 
is  a  sudden  paraplegia,  with  anaesthesia  or  ataxia  or  both.  The 
anaesthesia  is  often  dissociated,  there  being  loss  of  pain  and  thermic 
sense  with  retention  of  considerable  tactile  sense.  The  sphincters 
may  be  paralyzed;  the  urine  has  to  be  drawn.  The  reflexes  may 
be  abolished  at  first,  but  soon  return  and  become  exaggerated. 
There  is  considerable  pain  in  the  back.  If  the  lesion  is  high  up, 
the  arms  and  thorax  are  involved.  The  acute  symptoms  begin  usu- 
ally to  subside  at  the  end  of  seven  to  ten  days  and  the  disease  takes 
the  character  of  a  chronic  myelitis.  If  improvement  does  not  oc- 
cur, evidences  of  acute  myelitis  appear  and  the  patient  dies. 

I 'nt Ik, logy. — The  vessels  involved  are  the  central  arteries,  which 
supply  the  gray  matter  and  are  under  relatively  high  pressure. 
The  rupture  of  the  vessel,  when  due  to  disease,  is  caused  by  a  fatty 
degeneration  of  the  coats  or  syphilitic  endarteritis;  miliary  aneu- 
risms, such  as  are  found  in  the  brain,  rarely  develop  in  the  cord. 
Hemorrhage  often  precedes  or  begins  a  myelitis,  of  which  it  may 
be  the  cause  or  the  result.  The  clot  may  be  absorbed,  leaving  a 
cavity  as  in  the  brain;  or  the  broken-down  tissue  may  become  the 
centre  of  a  myelitic  focus.  The  hemorrhage  is  usually  single,  but 
there  may  be  several.     Multiple  capillary  hemorrhages  occur,  but 


240  DISEASES    OF    THE    NERVOUS    SYSTEM. 

usually  only  from  asphyxia  and  convulsions.  It  is  possible  that 
some  of  the  cases  of  disseminated  myelitis  occurring  after  infec- 
tious fevers  start  from  small  hemorrhages.  Hemorrhage  sometimes 
results  from  the  invasion  of  the  cord  by  a  new  growth,  as  in  syringo- 
myelia. 

Diagnosis. — The  points  to  be  noted  are  the  sudden  onset  without 
long  premonitory  symptoms,  and  the  absence  of  fever  followed  later 
by  gradual  improvement.  There  is  much  less  pain  than  in  menin- 
geal hemorrhage,  and  the  dissociation  of  cutaneous  sensations  is 
very  characteristic.  In  acute  softening  there  is  less  of  the  dissoci- 
ation of  sensations  and  usually  a  more  extensive  paralysis.  The 
disease  is  often  mistaken  for  acute  primary  myelitis,  which  does  in 
fact  often  follow  it.  Meningeal  hemorrhage  is  more  painful,  and 
there  is  less  paralysis,  more  spasm,  and  a  more  complete  recovery 
later. 

Prognosis.. — This  is  often  serious  as  regards  life,  and  always 
serio'us  as  regards  health.  It  depends  on  the  extent  and  seat  of  the 
hemorrhages.  Dorsal  hemorrhages  are  more  favorable,  cervical  the 
least. 

Treatment. — Absolute  rest,  ice  bags  to  the  spine,  and  small 
doses  of  aconite  given  early  are  all  that  can  be  tried,  except  the  use 
of  symptomatic  remedies.  Treatment  must  be  applied  at  once. 
The  late  treatment  is  the  same  as  that  for  -myelitis. 

THE  'CAISSON  DISEASE    (DIVER'S   PARALYSIS). 

The  caisson  disease  is  the  name  given  to  a  more  or  less  complete 
paraplegia  which  occurs  in  persons  who  work  in  caissons  or  diving- 
bells,  and  which  is  brought  about  by  the  sudden  return  from  a  con- 
densed air  to  the  normal  atmosphere. 

Etiology.. — Persons  employed  in  caissons  or  bells  work  usually 
under  a  pressure  of  from  one  to  four  atmospheres,  which  means  a 
pressure  of  from  fifteen  to  fifty  pounds  to  the  square  inch.  Acci- 
dents rarely  if  ever  occur  when  the  pressure  is  not  over  one  atmos- 
phere, and  they  are  also  rare  if  the  person  has  not  been  subjected 
to  the  pressure  for  at  least  an  hour.  Different  persons  vary  in 
susceptibility  to  the  effects  of  this  change  in  the  atmospheric  pres- 
sure, and  those  unused  to  the  work  are  more  liable  to  be  attacked. 
Naturally  the  disease  is  seen  only  in  men,  and  during  the  working 
period  of  life. 

The  symptoms  set  in  usually  very  soon  after  the  patient  has 
come  out  from  the  caisson,  but  they  may  be  delayed  for  half  a.n 
hour  or  more.     They  consist  of  intense  neuralgic  pains  in  the  lower 


THE    DISEASES    OF   THE    SPINAL   CORD.  241 

extremities,  often  affecting  especially  the  joints.  There  is  at  the 
same  time  epigastric  pain.  Nausea  and  vomiting  and  weakness  in 
the  lower  limbs,  amounting  in  some  cases  to  absolute  paralysis,  very 
soon  appear.  There  may  be  headache,  dizziness,  and  sometimes  even 
coma.  If  the  paralysis  is  considerable,  it  is  usually  accompanied 
by  anaesthesia.  Disturbances  in  the  sphincters,  with  retention  of 
urine  and  constipation,  may  also  be  present.  The  symptoms  vary 
very  much  in  severity,  from  pain,  weakness  in  the  legs,  and  nausea, 
up  to  frightful  neuralgic  attacks  and  complete  paralysis,  motor  and 
sensory.  The  upper  limbs  are  rarely  affected.  In  a  few  instances 
hemiplegia,  however,  has  been  observed.  The  disease  lasts  from 
a  few  hours  up  to  several  weeks.  Death  occurs  in  some  of  the  very 
severe  cases.  The  symptoms  having  reached  their  climax  gradually 
ameliorate,  and  a  complete  cure  is  not  infrequent.  In  some  in- 
stances, however,  the  patient  is  left  with  a  permanent  paraplegia 
and  the  ordinary  symptoms  of  a  transverse  myelitis. 

Pathology. — -When  the  patient  is  under  atmospheric  pressure  in 
the  caisson,  the  blood  is  driven  from  the  surface  of  the  body,  and 
the  internal  viscera,  including  the  brain  and  cord,  are  congested. 
The  sudden  change  from  the  abnormal  to  normal  pressure  produces 
a  rapid  flow  of  blood  from  the  internal  organs  to  the  periphery. 
The  viscera  not  inclosed  in  bony  cavities  are  enabled  to  relieve  them- 
selves of  this  congestion  without  much  harm,  but  the  circulation  in 
the  brain  and  spinal  cord  is  less  elastic;  that  in  the  spinal  cord  being 
less  even  than  that  in  the  brain.  The  result  is  that  congestions  and 
small  hemorrhages  ensue,  producing  a  destruction  of  the  nerve  tis- 
sue. In  other  cases  there  seems  to  be  a  blocking  up  of  some  of  the 
small  vessels,  with  consequent  softening  of  different  portions  of 
the  cord  and  to  a  less  extent  of  the  brain.  It  is  supposed  that  one 
element  in  producing  the  morbid  phenomena  is  the  escape  of  oxygen 
and  carbonic-acid  gas  from  the  blood  into  the  tissues  or  into  the 
blood-vessels.  This  mechanism,  however,  lias  not  been  proven.  It 
will  be  seen,  however,  that  on  the  whole  the  sudden  change  in  at- 
mospheric pressure  leads  to  vascular  disturbances  with  rupture  <>r 
obliteration  of  blood-vessels,  with  consequent  destruction  and  ne- 
crosis of  tissue.  Following  this  is  a  reactive  inflammation  pro- 
ducing the  phenomena  of  an  ordinary  acute  myelitis. 

The  treatment  is  largely  prophylactic.  The  workmen  engaged  in 
the  occupation  should  be  carefully  selected  and  should  accustom 
themselves  to  their  work.     They  should  spend  a  Longer time  in eom- 

•  it  of  the  caisson.  If  symptoms  supervene,  it  is  recommended 
that  they  be  put  back  under  a  slight   atmospheric  pressure  at   onee 

Until  these  symptoms  disappear.       When   the  disease  has  developed, 

16 


242  DISEASES   OF   THE   NERVOUS   SYSTEM. 

it  can  be  treated  only  by  symptomatic  remedies,  The  patient  should 
be  kept  quiet,  and  given,  if  necessary,  hypodermics  of  morphine. 
Dr.  A.  H.  Smith  recommends  the  use  of  ergot.  Later  on,  the  vari- 
ous neuralgic  and  paralytic  symptoms  may  be  treated  on  the  same 
principles  as  those  employed  in  myelitis. 


SPINAL  HYPEREMIA,  ACUTE  AND   CHRONIC. 

Etiology. — Acute  spinal  hyperemia  is  produced  by  sexual  ex- 
cesses, violent  physical  exertion,  suppression  of  menstrual  dis- 
charges, and  certain  poisons  like  strychnine.  It  occurs  also  in  the 
first  stage  of  acute  inflammatory  diseases. 

Chronic  spinal  hyperemia  is,  so  far  as  is  absolutely  known,  a 
very  rare  condition.  Chronic  hyperemia  of  the  membranes  may  be 
the  residuum  of  a  meningitis  or  of  injury,  and  these  are  probably 
the  most  common  causes.  As  to  the  causes  of  the  chronic  hyper- 
seniia  of  the  cord  substance  itself  independent  of  other  diseases,  we 
can  say  nothing  definitely. 

The  symptoms  of  acute  spinal  hyperemia  are  feelings  of  heavi- 
ness and  weight  in  the  limbs  and  around  the  loins,  numbness,  creep- 
ing sensations  and  actual  neuralgic  pains,  weakness  of  the  lower 
limbs,  with  twitchings  of  the  muscles.  There  may  be  also  some 
disturbances  in  the  sphincters,  though  of  this  one  can  speak  less  cer- 
tainly. The  symptoms  are  nearly  always  confined  chiefly  to  the  lower 
limbs.  The  statement  that  they  are  increased  by  lying  on  the  back 
and  ameliorated  by  lying  on  the  face  is  not  always  true,  since  pos- 
ture, unless  greatly  prolonged,  influences  but  very  slightly,  if  at  all, 
the  circulation  in  the  spinal  cord. 

The  symptoms  of  chronic  spinal  hyperemia,  when  this  hyper- 
emia involves  the  meninges  chiefly,  are  probably  somewhat  identi- 
cal with  those  of  spinal  irritation.  They  will  be  described  under 
that  head. 

Pathology. — The  circulation  of  the  blood  in  the  spinal  cord,  as 
has  been  shown  in  the  article  on  anatomy,  is  one  which  it  is  difficult 
to  disturb,  but  which,  once  disturbed,  is  rather  slow  in  being  brought 
back  to  its  normal  condition.  Thus  violent  activity  of  the  heart 
and  great  increase  in  the  arterial  pressure,  and  the  opposite  condi- 
tions of  weakened  heart  and  lowered  arterial  tension,  appear  but  lit- 
tle to  modify  the  spinal  functions.  Hence  it  is  unlikely  that  the 
large  number  of  clinical  symptoms  that  have  at  times  been  attrib- 
uted to  hyperemia  of  the  spinal  cord,  or  rather  to  disturbances  in  the 
circulation  of  the  spinal  cord,  have  really  been  due  to  that  cause. 

Treatment.— The  treatment  of  spinal  hyperemia  consists  in  the 
application  of  cups  to  the  back,  quiet  in  the  horizontal   position, 


THE    DISEASES    OF   THE    SPINAL    CORD.  243 

preferably  upon  the  side  or  face,  ice  and  counter-irritants  to  the 
spine,  morphine  and  bromides  internally.  In  the  more  chronic 
cases  muriate  of  ammonium,  iodide  of  potassium,  and  the  galvanic 
current  may  be  used.  The  use  of  ergot,  which  has  been  recom- 
mended, in  my  experience  has  been  found  of  little  or  no  value. 

SPINAL  ANAEMIA. 

Even  less  is  known  in  regard  to  the  etiology  and  symptomatology 
of  spinal  anaemia  than  of  spinal  hypersemia.  Undoubtedly  severe 
hemorrhages  or  diarrhoeal  discharges,  and  an  aortic  obstruction 
which  cuts  off  the  circulation  of  the  blood  from  the  spinal  cord,  will 
produce  a  spinal  anaemia,  and  when  this  is  severe  the  functions  of  the 
cord  are  nearly  abolished.  But  practically  we  do  not  know  of  any 
causes  which  produce  an  acute  or  chronic  anaemia  leading  to  serious 
and  prolonged  disturbances  in  the  spinal  functions,  aside  from  dis- 
eases of  the  arteries  of  the  spinal  cord  themselves,  such  as  occur  in 
advanced  life.  In  the  most  profound  anaemias,  which  must  affect 
equally  the  spinal  cord  with  other  organs,  very  little  special  disturb- 
ance of  this  organ  can  be  discovered.  Here,  too,  the  supposed  test 
of  improvement  on  lying  on  the  back  is,  in  the  writer's  opinion,  a 
fallacious  one.  It  has  been  customary  to  associate  with  spinal 
anaemia  a  class  of  symptoms  characterized  by  pains  in  the  back  of 
the  nature  of  spinal  irritation,  weakness  of  the  legs  amounting  to 
paraplegia — a  type  of  symptoms  that  has  been  called  spinal  concus- 
sion, but  it  is  impossible  in  the  present  stage  of  science  to  say  that  a 
spinal  anaemia  actually  underlies  and  causes  this  condition. 

INFLAMMATION    OF    THE    SPINAL    MEMBRANES     (SPINAL 
MENINGITIS). 

The  meningeal  inflammations  are : 

External  meningitis.  >»«•*•       u     ^ 

Internal  meningitis.  \  Affecting  the  dura  mater. 

Leptomeningitis.  -  Affecting  the  pia  mater. 

Hypertrophic  pachymeningitis.  [  Affecting  both  membranes. 

External  Meningitis,    Pachymeningitis  Externa  ("Com- 
pression M  vi.i.n  is"). 

Etiology. — The  disease  is  rare,  and  always  occurs  secondarily  to 
some  other  morbid  process.  This  process  is  in  most  cases  tubercu- 
losis and  causing  caries  of  the  vertebrae.  Other  causes  are  suppura- 
tive inflammation  in  the  neighborhood  of  the  vertebrae,  psoas  ab- 
scess, purulent  pleurisy,  peritonitis,  ami  puerperal  pyaemia.  'When 
the  disease  arises  from  inflammations  in  the  visceral  cavities,  it  is 
thought  to  be  caused  by  an  ascending  neuritis. 


244  DISEASES    OF   THE   NERVOUS    SYSTEM. 

Symptoms. — The  symptoms  are  those  of  irritation  of  the  motor 
and  sensory  roots;  later,  compression  of  them  and  of  the  spinal 
cord,  local  pain  in  the  back,  radiating  pains,  tenderness,  hyper- 
esthesia, twitching,  paresis,  paraplegia,  exaggeration  of  reflexes, 
and  involvement  of  the  sphincters.  Anaesthesia  occurs  in  severe 
forms. 

The  disease,  when  chronic,  may  extend  to  the  other  membranes 
and  cord,  causing  what  is  termed  "compression  myelitis." 

Pathological  Anatomy. — The  inflammation,  if  acute,  is  generally 
a  fibro-purulent  one,  this  being  the  form  usually  caused  by  vertebral 
caries.  The  dura  mater  is  covered  by  a  layer  of  caseous,  semi- 
solid matter,  often  very  thick  and  most  extensive  posteriorly.  It 
involves  the  dura  vertically  for  several  inches.  In  chronic  forms 
the  deposit  is  made  up  of  connective  tissue  and  the  cord  is  com- 
pressed. In  purely  suppurative  forms  the  cellular  tissue  outside 
the  dura  is  infiltrated  with  pus  throughout  a  great  part  of  the  canal. 

The  diagnosis  is  based  on  the  presence  of  the  primary  local  dis- 
ease, the  kyphosis,  the  radiating  pains,  and  tenderness,  and  by  the 
combination  of  motor  and  sensory  irritation  and  paralysis. 

The  prognosis  is  generally  bad,  because  the  original  disease  is  a 
serious  one.  Still,  surprisingly  good  results  are  often  obtained  when 
the  disease  is  taken  early. 

The  treatment  consists  in  attention  to  the  local  caries  or  inflam- 
matory focus.  It  is  therefore  purely  surgical.  Some  kind  of  jacket 
is  almost  always  indicated. 

Internal  Meningitis,  Pachymeningitis  Interna,  Hemor- 
rhagjo  and  hypertrophic. 

Inflammation  of  the  inner  surface  of  the  dura  mater  occurs  in 
two  forms — the  hemorrhagic  and  the  hypertrophic.  As  the  latter 
is  generally  but  a  sequel  of  the  former,  I  shall  describe  the  two 
together  under  the  head  of  hypertrophic  pachymeningitis. 

Etiology. — The  disease  occurs  almost  always  in  adult  life.  A 
few  cases  have  been  reported  in  children  (Gibney).  It  usually  af- 
fects males.  Syphilis,  alcoholism,  exposure,  and  trauma  are  excit- 
ing causes,  the  first  and  last  being  by  far  the  most  important  factors 
in  the  disease.  My  own  experience  is  that  the  disease  is  always  a 
syphilitic  process. 

Symptoms. — The  disease  begins  gradually  with  symptoms  of  ir- 
ritation (irritative  stage).  The  patient  suffers  from  pain  and  stiff- 
ness in  the  neck.  The  pains  radiate  up  to  the  occiput  and  down  the 
back ;  numbness,  prickling,  and  pain  are  felt  in  the  arms,  more  in 
one  than  the  other.  The  pains  exacerbate  and  are  worse  at  night. 
Stiffness  and  cramps  may  affect  the  arms.  Nausea  and  vomiting 
sometimes  occur. 

After  five  or  six  months  symptoms  of  paralysis  appear  (paralytic 
stage).     The  arms  are  affected.     They  become  weak,  atrophy  occurs, 


THE    DISEASES   OF   THE    SPINAL    CORD.  245 

associated  with  contractures  and  rigidity.  There  is  still  pain,  and 
in  addition  anaesthesia,  hyperesthesia,  and  trophic  changes  occur. 
Later,  paraplegia,  with  rigidity,  exaggerated  reflexes,  and  spinal 
trepidation  develop.  The  patient  becomes  weaker,  and  finally  dies 
of  exhaustion  or  from  some  intercurrent  trouble.  The  disease  some- 
times takes  what  is  called  \hejperiphepal  type.  Then  the  symptoms 
are  more  localized  in  the  extremities.  Usually  it  is  of  the  cervical 
type  and  presents  symptoms  as  described  above.  In  either  form  the 
disease  is  a  chronic  and  painful  one. 

(Pathology. — The  disease  starts  as  a  hemorrhage  upon  the  surface 
of  the  dura.  This  leads  to  a  chronic  inflammatory  process,  new  hem- 
orrhages occur,  and  a  fresh  inflammatory  deposit  is  made  until  the 
cord  is  finally  encircled  and  compressed  by  a  dense  connective-tissue 
mass,  which  involves  the  pia  and  to  some  extent  the  cord  substance. 
The  process  is  analogous  to  that  of  cerebral  pachymeningitis  haemor- 
rhagica.  The  cervical  region  is  usually  attacked.  In  other  cases 
the  lesion  is  a  syphilitic  gummatous  process. 

Prognosis. — A  few  cases  have  been  reported  practically  cured. 
More  cases  terminate  in  death.  Sometimes,  however,  the  disease 
comes  to  a  standstill  for  a  long  time. 

Diagnosis. — This  must  be  made  from  tumor,  myelitis,  Pott's  dis- 
ease, wryneck,  and  progressive  muscular  atrophy.  The  history  of 
injury,  the  slow  progressive  course,  and  the  localization  of  the  symp- 
toms, their  bilateral  character  and  the  pain,  give  the  most  help. 
It  is  not  always  passible  to  exclude  a  tumor.  In  spinal  tumor  the 
symptoms  at  the  beginning  are  more  sharply  localized.  They  de- 
velop mi  ire  rapidly  and  the  course  of  the  disease  is  shorter  than  in 
meningitis.  Tumor  though  rare  is  really  much  more  common  than 
pachymeningitis.  It  is  probable  that  some  cases  described  as  this 
were  really  forms  of  syphilis  of  the  cord. 

Treatment. — The  not  rare  syphilitic  origin  of  the  disease  must 
be  borne  in  mind.  Counter-irritants,  electricity,  hydrotherapy,  and 
symptomatic,  remedies  for  the  pain  and  spasms  are  indicated.  It  is 
possible  that  surgery  may  help  these  cases. 

Acute  Spinal  Leptomeningitis  (Inflammation  of  the  Pia 
Mateb  of  the  Spinal  Cord). 

Etiology* — This  is  a  rare  disease,  sccorring  alone,  but  is  common 
in  concction  with  disease  of  the  cerebral  pia  mater. 

Children  are  oftenest i affected;  and  among  adults,  males.  Al- 
coholism predisposes  to  it.  The  disease  is  always  secondary  to  an 
infection  with  or  without  a  truumat  ism.  The  infections  are  tuber- 
cle, syphilis,  typhoid  fever,  and  various  pyogenic  microbes.  Exten- 
sion of  inflammation  from  neighboring  part*  and  surgical  operations 
are  occasional  causes.  Tic  oases  attributed  to  rheumatism,  expo- 
sure, insolation,  are  in  reality  dueto  some  infection,  and  the  virus 
of  cerebro-spinal  fever  sometimes  attacks  the  cord  alone. 


246  DISEASES    OF   THE    NERVOUS   SYSTEM. 

Symptoms.  — The  disease  begins  with  pain  in  the  back,  radiating 
along  the  nerves.  There  are  usually  a  chill  and  some  fever.  The 
pulse  may  be  fast  or  slow.  The  pain  increases,  and  is  accompanied 
by  dorsal  tenderness  and  rigidity  of  the  muscles  of  the  back, 
amounting  sometimes  to  opisthotonos.  The  skin  is  very  hyperses- 
thetic  and  the  reflexes  are  at  first  increased.  There  is  constipation, 
and  sometimes  retention  of  urine.  After  a  time  symptoms  of  pa- 
ralysis come  on,  with  anaesthesia  and  retention  of  urine.  The  patient 
becomes  weaker,  bedsores  may  form,  and  death  from  exhaustion 
follow.     The  disease  lasts  from  a  few  days  to  several  weeks. 

The  dominant  symptoms  in  the  first  stage  are  those  of  irritation, 
viz.,  pain  in  the  back  and  along  the  nerves,  hyperesthesia,  and 
muscular  spasm.  In  the  second  stage,  paralysis,  atrophy,  and 
anaesthesia. 

In  the  tuberculous  form  of  meningitis  the  symptoms  come  on  more 
slowly.  In  septic  meningitis  the  symptoms  are  of  the  severe  and 
typical  kind  described.  In  meningitis  from  other  infections  the 
symptoms  are  not  so  severe,  as  a  rule. 

Pathological  Anatomy. — Acute  leptomeningitis  shows  a  some- 
what different  exudate  according  to  the  nature  of  the  infecting  micro- 
organisms. The  common  form  is  the  suppurative  exudate,  which 
may  be  due  to  the  streptococcus  pyogenes  and  other  pyogenic  micro- 
organisms, and  to  the  pneumococcus.  The  purulent  matter  is  usu- 
ally distributed  along  the  whole  length  of  the  cord,  but  more  poste- 
riorly and  often  more  in  its  lower  portion.  It  may  also  be  localized 
chiefly  at  certain  levels.  The  spinal  fluid  is  increased  in  amount. 
The  arachnoid,  the  inner  surface  of  the  dura,  and  the  tissue  of  the 
cord  itself  are  usually  involved.  If  the  disease  lasts  several  weeks, 
the  purulent  matter  is  absorbed  in  part  and  an  increase  in  connec- 
tive tissue  takes  place,  binding  the  dura,  arachnoid,  and  pia  to  the 
cord.  The  nerve  roots  are  surrounded  and  compressed  by  the 
inflammatory  product. 

In  tuberculous  meningitis  there  is  less  exudate.  It  is  more  of  a 
fibrinous  character,  and  grayish  in  appearance.  Tubercle  granula- 
tions are  seen  distributed  over  the  pia,  arachnoid,  and  inner  surface 
of  the  dura.  Simple  exudative  meningitis  rarely  occurs.  The 
inflammatory  process  often  ends  in  a  production  of  new  connec- 
tive tissue  and  sometimes  the  establishment  of  a  chronic  lepto- 
meningitis. 

The  diagnosis  must  be  made  from  myelitis,  tetanus,  rabies,  rheu- 
matism of  the  dorsal  muscles,  gonorrhceal  rheumatism,  and  strych- 
nine poisoning.  In  myelitis  there  is  relatively  little  pain  and  much 
paralysis;  in  tetanus  there  is  trismus,  fever  is  absent,  and  there  is 
a  history  of  trauma. 


THE    DISEASES    OF   THE    SPINAL   CORD.  247 

Tuberculous  meningitis  comes  on  more  slowly,  is  rarely  spinal 
alone,  and  there  may  be  evidence  of  local  tuberculosis  elsewhere. 

The  prognosis  is  not  good,  but  is  especially  bad  in  tuberculous 
meningitis  and  in  cases  with  high  fever,  severe  pains,  and  early 
paralysis.  Chronic  meningitis  sometimes  remains  after  the  acute 
symptoms  subside. 

Treatment. — This  consists  first  in  perfect  rest  and  quiet;  leeches 
should  be  applied  along  the  spine,  then  hot  poultices  or  ice  bags ; 
opium  is  to  be  given  for  relief  of  pain;  mercurial  purges  and  small 
doses  of  iodide  of  potassium  or  sulphate  of  magnesium  may  be  given 
at  short  intervals.  Later,  blisters  and  counter-irritation  and  luke- 
warm baths  are  indicated. 

Chronic  Leptomeningitis  and  Meningo-myelitis. 

Etiology.  —This  disease,  which  used  to  be  often  diagnosticated, 
is  now  believed  to  be  rare,  and  always  secondary  to  an  acute  proc- 
ess, such  as  a  cerebro-spinal  meningitis,  or  to  syphilis  and  perhaps 
chronic  alcoholism.  It  occurs  oftenest  in  adults  and  in  males. 
Trauma,  and  especially  concussion  of  the  spine,  used  to  be  thought 
a  frequent  cause,  but  in  most  of  such  cases  the  trouble  is  simply  a 
hypersemia  or  else  neuralgic  and  functional. 

The  symptoms  gradually  develop  after  an  acute  meningitis  or  an 
injury,  and  they  are  the  same  in  character  as  those  of  the  acute  proc- 
ess. There  are  pam  in  the  back,  increased  on  movement  and  radiat- 
ing about  the  trunk  and  down  the  limbs ;  tenderness  along  the  spine, 
stiffness  of  the  back,  twitching  and  spasms  in  the  limbs  with  some 
weakness,  and  later  some  paralysis,  wasting,  and  anaesthesia,  with 
weakness  of  the  bladder.  These  paralytic  symptoms,  if  severe, 
however,  mark  an  invasion  of  the  spinal  cord.  Cutaneous  erup- 
tions, such  as  herpes,  may  appear.  The  symptoms  run  an  irregu- 
lar course,  with  periods  of  improvement.  They  always  become  less- 
when  the  patient  rests. 

Pathological  Anatomy. — The  inflammation  consists  of  a  prolifer- 
ation of  connective  tissue  (productive  inflammation  of  Delafield). 
The  result  is  a  thickening  and  opacity  of  the  pia  mater  and  arach- 
noid. The  dura  mater  may  be  involved,  but  only  in  severe  cases. 
The  process  may  invade  the  spinal  cord,  causing  an  "annular"  or 
ringlike  sclerosis,  from  which  the  disease  extends  into  the  cord  in 
wedge-shaped  masses  at  various  parts,  causing  eventually  an  involve- 
ment of  fibre  systems  and  secondary  degenerations  up  and  down. 
This  somewhat  rare  terminal  condition  is  called  meningo-myelitis. 
In  syphilitic  meningitis  the  lesion  usually  involves  only  part  of  the 
spinal  cord,  usually  some  of  the  dorsal  segments.      Here  there  is 


248  DISEASES   OF   THE    NERVOUS   SYSTEM. 

the  characteristic  exudate  of  syphilis,  not  of  a  simple  proliferative 
inflammation. 

The  diagnosis  must  be  made  from  spinal  irritation,  locomotor 
ataxia,  myelitis,  vertebral  caries,  and  tetanus.  In  spinal  irritation 
there  are  not  the  rigidity,  severe  radiating  pains,  twitchings,  atro- 
phy, or  paralysis;  and  neurasthenia  or  hysteria  exists.  In  locomo- 
tor ataxia  the  knee  jerk  is  lost,  there  is  ataxia,  and  there  is  little 
paralysis,  nor  is  there  local  tenderness  over  the  spine. 

In  vertebral  caries  the  pain  and  tenderness  are  much  more  local- 
ized, and  there  is  spasmodic  fixation  of  the  trunk.  The  pain  is 
more  continuous  and  dull,  and  is  increased  by  lateral  pressure  and 
lessened  by  extension.  There  is  usually  also  some  deformity.  If 
compression  occurs  there  is  exaggeration  of  the  reflexes  and  para- 
plegia, without  much  anaesthesia.  After  all,  however,  with  Pott's 
disease  there  may  be  a  local  meningitis. 

Treiitnii'iit. — As  chronic  meningitis  is  usually  the  product  of 
syphilis,  or  the  relic  of  traumatism  or  of  an  acute  process,  the  indi- 
cations for  treatment  are  simple.  Rest  is  the  essential  thing.  With 
this  can  be  combined  the  systematic  and  persistent  use  of  counter- 
irritants.  The  hot  iron  is  usually  best,  because  its  wounds  heal  so 
quickly.  Cupping  is  also  useful  if  done  vigorously  and  often.  In- 
ternally, iodide  of  potassium,  small  doses  of  bichloride  of  mercury, 
nitroglycerin,  and  digitalis  may  be  given ;  also  the  salicylates  and 
ergot.  Both  the  latter  drugs  should  be  employed  in  large  doses, 
if  at  all.  Electricity  in  the  form  of  galvanism,  and  cocaine  by  local 
injection  or  cataphoresis.  may  be  tried.  Splints  and  plaster  jackets 
are  of  much  service  in  some  cases. 


CHAPTER   XIII. 

MYELITIS -INFLAMMATION   OF   THE    SPINAL   CORD. 

Myelitis  is  an  inflammation  of  the  spinal  cord.  It  may  be 
acute,  subacute,  or  chronic 

It  may  affect  the  anterior  horns  chiefly,  when  it  is  called  ante- 
rior poliomyelitis ;  or  both  the  gray  and  white  matter,  when  it  is 
called  diffuse  myelitis  and  transverse  myelitis.  The  forms  are  still 
further  divided,  in  accordance  with  their  location,  into  cervical, 
dorsal,  lumbar,  and  disseminated  myelitis.  Myelitis  is  given  dif- 
ferent names  also  in  accordance  with  its  cause.  Thus  we  have 
hemorrhagic  myelitis,  a  form  in  which  the  initial  process  is  due  to 
or  associated  with  a  hemorrhage;  compression  myelitis,  due  to  ver- 
tebra! caries:  septic  or  purulent  myelitis  or  abscess  of  the  cord;  and 
tuberculous  and  syphilitic  myelitis. 

For  practical  purposes  the  following  classification  is  sufficient: 


Acute  myelitis:  (  1.   Anterior  poliomyelitis. 

«"•  - «-  -  -i*.     /  l  '''r^;™:™"""'  -  ,INs,,",i" 

"With  suppuration.  [3.  Abscess  of  ■cord. 

Chronic  myelitis:  (4.  Chronic  anterior  poliomyelitis. 

With  necrosis  and  proliferation.      I  5.  Transverse  myelitis. 

S.  Compression  myelitis. 


Acute  Tk  w-vKKsi:  Myki.itis  (Acute  Softewimo  ot  the  Simnai. 

<  'o|;l>.  i 

Acute,  diffuse, or  isansverae  myelitis  represents  several  different 
pathological  processes.  It  may  be  a  local  infection  causing  exuda- 
tive iiiHammat  ion.  with  more  or  Less  necrosis  resembling  acute  ante- 
rior poliomyelitis.  The  diHerence  in  the  symptoms  here  depend 
only  on  the  severity  of  the  infection,  its  capiditj  of  course  and  ex- 
tent. It  may  be  initialed  or  accompanied  by  a  hemorrhage  or  soft- 
ening from  thrombosis  of  arteries,  and  the  latter  is  often  the  case. 
Nbf  can  we   clinically  distinguish    between    the   cases   due   to  a  pri- 


250  DISEASES    OF   THE    NEKVOUS    SYSTEM. 

mary  infection  and  those  due  to  a  hemorrhage  and  softening.  Vari- 
ous pathogenic  microbes  have  been  found,  but  they  are  not  always 
present  even  in  real  infections ;  because  the  microbe  after  starting 
its  work  is  absorbed  and  disappears. 

Hence  acute  transverse  myelitis  may  mean  either  an  acute  in- 
flammatory process  or  an  acute  softening. 

Etiology. — Predisposing  causes  are  a  neuropathic  constitution, 
the  male  sex,  early  adult  life,  occupations  calling  for  exposure,  and 
muscular  strain.  The  exciting  causes  are  exposure  to  cold,  blows, 
falls,  fractures,  strains,  extension  from  neighboring  organs,  syphilis, 
infective  fevers,  and  septic  infection.  Injury  is  frequently  an  ap- 
parent cause.  But  most  of  these  causes  produce  primarily  mechan- 
ical destruction,  hemorrhages,  or  thromboses,  and  the  inflammation 
is  secondary. 

Symptoms. — Prodromal  symptoms  are  rarely  present,  but  there 
may  be  slight  paraesthesias  or  pain  in  the  back  and  limbs.  Some- 
times there  is  a  chill,  and  in  a  few  instances  convulsions  have  been 
noticed. 

The  initial  symptoms  consist  of  feelings  of  numbness,  usually  in 
the  feet  and  legs,  which  seem  heavy  and  weak.  Some  pain  may  be 
felt  about  the  back.  The  patient  soon  finds  that  he  cannot  walk 
easily,  that  he  moves  his  legs  with  an  effort  and  that  they  feel  stiff. 
In  a  few  hours  or  perhaps  not  till  one  or  two  days,  a  paraplegia  with 
anaesthesia  has  developed,  and  if  the  lesion  is  in  the  cervical  cord 
the  arms  are  paralyzed  also.  All  these  symptoms  may  come  on  in 
the  daytime  or  during  sleep.  Retention  or  incontinence  of  urine 
and  constipation  are  early  symptoms.     There  may  be  some  fever. 

Symptoms  of  the  Attack. — If  the  patient  is  examined  when  the 
malady  reaches  its  height,  it  will  be  found  that  he  cannot  walk  or 
stand,  but  can  move  his  legs  a  little.  He  complains  of  a  sensation 
like  a  band  around  his  waist  or  at  the  level  of  the  spinal  lesion  (gir- 
dle symptom).  His  legs  feel  numb  and  heavy,  but  there  is  little 
pain  and  no  tenderness.  Anaesthesia  to  touch,  pain,  and  tempera- 
ture exists  in  various  degrees  on  the  limbs,  as  high  up  as  the  lesion. 
The  anaesthesia,  if  not  total,  is  greatest  to  touch,  next  to  tempera- 
ture, and  least  to  pain.  He  has  vesical  anaesthesia ;  the  urine  is 
retained  and  he  has  to  have  it  drawn.  The  bowels  are  constipated, 
but  if  enemata  are  given  the  faeces  may  pass  away  without  his  knowl- 
edge, owing  to  rectal  anaesthesia.  If  the  lesion  is  lumbar,  there  is 
abolition  of  the  sexual  power ;  but  if  dorsal  or  cervical,  strong  erec- 
tions may  occur  without  the  patient's  feeling  them.  When  the  le- 
sion is  above  the  lumbar  cord,  also,  the  bladder  may  automatically 
and  forcibly  contract  and  expel  the  urine.     In  time  the  bowels  re- 


MYELITIS — INFLAMMATION    OF   THE    SPINAL   CORD.  251 

gain  some  power.  The  paralysis  in  the  limbs  affects  the  flexors  of 
the  feet  and  legs  more  than  the  extensors.  The  patient  can  push 
down  his  limbs  better  than  he  can  draw  them  up. 

The  temperature  of  the  limbs  for  a  few  days  is  raised,  but  after 
this  it  falls  a  few  degrees  below  normal.  The  skin  becomes  rough, 
cold,  congested;  and  excessive  perspiration  may  take  place.  The 
general  bodily  temperature  is  usually  normal  throughout  the  dis- 
ease, but  in  some  cases  a  fever  develops  of  102°  to  104°  and  contin- 
ues.    The  prognosis  is  then  bad. 

Bed-sores  may  develop  early,  within  a  few  days  or  weeks.  They 
appear  oftenest  upon  the  buttocks  and  heels,  and  are  due  to  trophic 
disturbance,  combined  with  pressure  and  pyogenic  infection  of  the 
parts. 

If  the  lesion  is  lumbar,  the  tendon  and  skin  reflexes  are  much 
weakened  and  the  paralysis  is  somewhat  flaccid.  The  muscles  also 
tend  to  waste  and  show  degenerative  reactions.  If  the  lesion  is 
dorsal,  as  is  more  often  the  case,  the  reflexes  are  present,  and  after 
a  time  become  exaggerated ;  there  is  ankle  clonus  and  a  flexor  re- 
sponse on  irritating  the  soles  of  the  feet ;  contractures  and  spasms 
develop;  the  legs  become  drawn  up  and  deformities  are  produced. 
If  the  lesion  is  so  complete  as  entirely  to  cut  across  the  cord,  there 
may  still  be  some  excessive  muscular  tension,  but  the  reflexes  will 
be  abolished  (Bastian) .  When  the  cervical  region  is  attacked  the 
anus  are  involved  as  well  as  the  legs,  and  generally  to  a  severer 
extent.  There  may  now  be  also  unequal  dilatation  of  the  pupils 
from  involvement  of  the  cilio-spinal  centre ;  and  optic  neuritis  from 
some  cause  has  been  known  to  occur.  In  extensive  involvement  of 
the  upper  part  of  the  cord  there  may  be  paralysis  of  the  intercostal 
muscles  and  disturbance  of  the  heart's  action. 

The  disease,  having  in  a  few  days  reached  its  height,  usually  re- 
mains stationary  for  a  few  weeks,  and  then,  should  the  patient  live, 
improvement  slowly  sets  in.  In  some  cases  evidences  of  extension 
upward  or  downward  occur  (ascending  or  descending  myelitis)  ;  the 
symptoms  become  more  severe,  and  in  a  few  weeks,  or  oftener 
months,  death  occurs. 

As  improvement  begins,  a  return  of  sensation  is  first  noticed 
(one  to  six  months) ;  this  is  followed  by  return  of  more  or  less  mo- 
tion (six  to  eighteen  months).  Spasms  and  contractures  now  de- 
velop, owing  to  a  descending  degeneration.  A  certain  amount  of 
ataxia  from  ascending  degeneration,  with  a  little  anaesthesia  of  the 
skin,  may  remain,  so  that,  if  the  patient  has  sufficient  motor  power 
to  walk  somewhat,  he  presents  many  features  of  "  ataxic  paraplegia" 
(see  p.  305). 


252  DISEASES   OF  THE   NERVOUS   SYSTEM. 

Some  improvement  may  be  expected  for  from  one  to  two  years. 
A  few  cases  get  almost  entirely  well.  The  majority  become  more 
less  or  paraplegic  and  bedridden,  in  which  condition  they  are  re- 
garded as  cases  of  chronic  myelitis. 

I'ctJiolnijiral  Anatomy. — The  early  changes  found  in  acute  mye- 
litis are  those  of  inflammation,  hemorrhagic  extravasation,  and  soft- 
ening. Often  it  is  impossible  to  say  whether  the  primary  process 
was  inflammatory  or  due  to  a  hemorrhage  or  softening. 

Microscopically,  the  cord  at  the  affected  part  appears  soft,  swol- 
len, and  either  red  and  hyperaemic  or  pale  and  anaemic.  In  rare 
eases  no  change  is  apparent  to  the  naked  eye.  In  later  stages  the 
parts  are  white  Or  gray,  shrunken,  and  hard.  The  cord  may  be  re- 
duced to  a  thin  shred.  The  meninges  about  the  affected  parts  are 
often  thickened,  inflamed,  and  adherent. 

Microscopically,  if  the  process  is  primarily  inflammatory  we  find 
intense  congestion,  distended  blood-vessels,  emigrated  white  blood 
cells  in  great  number,  especially  in  the  perivascular  spaces,  swollen 
axis  cylinders  and  ©edematous  swelling  of  the  myelin  sheath,  red 
blood  cells,  cells  filled  with  fat  granules  known  as  compound  gran- 
ular corpuscles,  or  Gluge's  corpuscles.  These  are  leucocytes  which 
have  taken  up  fat  granules.  A  peculiar  form  of  cell,  stellate  in 
shape,  known  as  spider  cells  or  Deiter's  cells,  may  be  seen.  They 
are  proliferated  neuroglia  cells.  The  nerve  cells  lose  their  granular 
or  reticular  appearance,  become  homogeneous,  swell  up,  fat  granules 
appear  in  them,  and  a  peculiar  coagulation  process  attacks  the  cell 
and  body.  The  cell  processes  retract,  become  thick,  and  finally 
drop  off.  Vacuoles  are  sometimes  seen  in  the  nerve  cells ;  but  these 
are  very  rare  if  the  tissue  is  properly  preserved.  Besides  the  above 
evidences  of  vascular  and  connective-tissue  activity  and  of  cell  de- 
struction, one  sees  granular  matter,  broken-down  nerve  fibres,  and 
other  evidences  of  nerve  disintegration.  Pigment  or  extravasations 
of  blood,  and  in  later  stages  bodies  resembling  starch  granules  (cor- 
pora amylacea),  may  be  seen.  They  are  probably  modifications  of 
the  myelin  substance.  If  the  lesion  is  primarily  softening  there 
may  be  much  congestion,  but  the  blood-vessels  are  less  distended 
and  fewer  white  cells  are  found  in  the  perivascular  spaces.  The 
connective-tissue  cells  are  less  numerous.  The  nerve  cells  are  swol- 
len, glassy,  and  stain  badly.  There  is  a  great  deal  of  granular 
matter  and  nerve  detritus.  It  is  thought  that  in  inflammatory 
swelling  of  the  nerve  cells  they  take  up  the  carmine  stain,  but  in 
degenerative  changes  they  do  not.* 

*  In  the  different  stages  of  acute  degeneration,  the  nerve  cells,  particu- 
larly those  of  the  anterior  horns,  show  various  appearances.     These  have  been 


MYELITIS — INFLAMMATION    OF   THE    SPINAL   COED.  253 

The  connective-tissue  changes  are  most  noticeable  in  the  white 
matter.  The  axis  cylinder  and  myelin  sheath  are  here  often  so  dis- 
integrated that  in  thin  sections  they  drop  out,  leaving  holes  in  the 
section  and  giving  it  a  -vacuolated  appearance.  The  lesion,  whether 
destructive  or  inflammatory,  may  extend  up  or  down  the  cord,  often 
in  the  course  of  certain  tracts.  Sometimes  a  destructive  process 
extends  a  long  way  through  the  central  part  of  the  cord  (perforating 
necrosis). 

After  three  or  four  weeks,  if  the  patient  lives,  the  process  of 
absorption  and  cicatrization  begins,  and  secondary  degenerations 
are  seen.  The  granular  and  fatty  matters  and  leucocytes  disappear, 
the  blood-vessels  are  thick-walled  and  distended  but  less  numerous, 
connective  tissue  gradually  takes  the  place  of  the  destroyed  nerve 
cells  and  fibres.  The  axis  cylinder  is  the  last  to  be  destroyed  and 
has  the  greatest  power  of  recuperation.  The  nerve  cell,  if  once  de- 
stroyed, is  never  developed  again.  The  cord  at  the  point  or  points 
inflamed  or  softened  becomes  reduced  to  a  mass  of  connective  tissue 
containing,  perhaps,  a  few  nerve  fibres  and  cells.  In  this  Btage 
the  condition  is  one  that  is  known  as  chronic  myelitis.  In  some 
cases  a  cyst  is  formed  in  the  affected  region. 

In  fatal  cases  the  inflammation  and  softening  continue;  fresh 
areas  of  cord  are  involved,  much  meninegal  exudation  takes  place 
and  finally  death  occurs.  The  process  may  in  very  rare  cases  be 
still  more  acute,  suppuration  and  abscess  occur,  and  here  death  also 
rapidly  ensue-. 

The  inflammatory  and  softening  processes  above  referred  to  are 
ribed  in  accordance  with  their  appearance  as  red  softening, 
yellow  softening,  or  white  softening.  A  form  of  so-called  inflamma- 
tion known  as  inflammatory  oedema  is  also  described'.  It  is  an 
abortive  inflammation,  "a  lymphatic  congestion,"  analogous  to  vas- 
cular congestion. 

The  diagnosis  of  acute  myelitis  must  be  made  from  hemorrhage, 
aeate  embolic  or  thrombotic  softening,  acute  ascending  paralysis, 
multiple  neuritis,  meningitis,  and  meningeal  hemorrhage,  and  hys- 
d,  or  functional  paralysis.  Spinal  hemorrhage  comes  on  sud- 
denly and  is  usually  not  attended  by  lever.  If  meningeal,  it  is 
attended  with  pain.  Acute  softening  cannot  always  be  distinguished 
from  acute  myelitis,  of  which  it  is  probably  the  starting-poinl  in  many 

described  by  Friedmann  as.  1,  homogeneous  swelling,  hyaline  swelling  j  2, 
sclerosis;  3,  simple  atrophy;  4,  fatty  and  molecular  decomposition  ;  5,  cloudy 

swelling.  The  degeneration  begins  in  the  cell  body  and  then  Involves  the 
processes  and  the  nucleus;  finally  the  whole  cell  is  involved.  Nerve  cells 
do  not  often  undergo  the  acute  general  death  called  coagulation  necrosis 
(Friedmann),  though  the  process  of  sclerosis,  so  called,  resembles  it  somewhat, 


254 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


cases.  In  softening  there  is  no  leukocytosis,  the  process  is  slower, 
there  is  less  pain  and  the  dissociation  of  cutaneous  sensations  is  less 
marked.  In  acute  ascending  paralysis  the  disease  is  progressive,  there 
are  no  involvement  of  sensation,  no  atrophy,  and  little  change  in  the 

electric  irritability.  In 
multiple  neuritis  the  onset 
is  slower,  there  are  more 
pain  and  local  tenderness 
and  sensory  disturbance, 
and  the  bladder  and  rec- 
tum are  rarely  involved. 
In  meningitis  there  are 
pain  and  tenderness  in 
the  back  and  limbs,  rigid- 
ity, cramps,  a  little  pa- 
ralysis, and  no  bladder 
trouble.  In  hysterical 
paraplegia  there  are  no 
marked  atrophic  changes, 
but  little  spasm  or  ri- 
gidity, no  electrical  chan- 
ges, and  the  stigmata  of 
hysteria  may  be  found. 
The  sensory  disturbances 
are  variable  and  some- 
what characteristic  (see 
Hysteria),  and  the  knee- 
jerks  are  not  greatly  if  at 
all  exaggerated. 

The  diagnosis  of  the 
location  of  the  lesion  is 
made  by  studying  the 
height  of  the  anaesthesia, 
the  skin  reflexes  (see  p. 
47),  and  the  distribution 
and  extent  of  the  paraly- 
sis. There  is  often  a 
differentiation  of  the  an- 
aesthesia as  shown  in 
Figs.  117  and  116.  Le- 
sions of  the  lumbar  re- 
gion involving   the    gray 


Fig.  116.— Acute  Transverse  Myelitis  of  Lumbar 
Cord,  showing  distribution  of  anaesthesia.  Area  in 
lines=total  anaesthesia  and  analgesia.  Dotted  area 
= analgesia  only. 


matter  cause  very  complete  paraplegia  with  sphincter  troubles  and 
degenerative  electrical  reactions.     Lesions  in  the  dorsal  cord  cause 


MYELITIS — INFLAMMATION    OF   THE    SPINAL    CORD. 


255 


a  less  complete  paraplegia,  but,  owing  to  the  secondary  descending 

degenerations  of  the  lateral  column,  rigidity,  exaggeration  of  the 

deep  reflexes,  and  contractures  occur.     Lesions  of  the  cervical  cord 

cause    paralysis    of    the 

arms,    with    degenerative 

reactions  in  the  muscles. 

The  paraplegia  is  spastic 

and    there   is   not    much 

muscular  wasting.    If  the 

lesion      cuts      entirely 

through     the     cord     the 

limbs    are   paralyzed  and 

may  be   somewhat   rigid, 

but  the  deep  reflexes  are 

absent. 

Prognosis. — The  prog- 
nosis is  worse  the  more 
complete  and  extensive 
the  paralysis.  It  is 
worse  in  serious  motor 
paralyses  than  when  sen- 
sation is  chiefly  involved. 
It  is  best  in  dorsal  myelitis 
and  worst  usually  in  cer- 
vical myelitis,  other 
things  being  equal .  Bed- 
sores and  slight  fever  ar6 
unfavorable  signs;  so 
also  is  severe  involvement 
of  the  bladder  and  rec- 
'  turn.  Recovery  of  sen- 
sation gives  good  hope  of 
recovery  of  some  motion. 
Total  absence  of  recovery 
of  sensation  and  motion 
after  six  months  is  very 
unfavorable.  Improve- 
ment may  be  expected  up 
to  eighteen  months  after 
the  onset,  and  in  some 
cases  even  longer.  In 
compression  myelitis  there  is  more  chance  of  recovery  than  in  the 
other  forms.  Syphilitic  cases  have  a  more  favorable  prognosis. 
Treatment. — In  the  attack,   the  patient  must  be  put  to  bed; 


Fio.  117.— Acute  Transverse  Myelitis  op  Lumbar 
Cord,  showing  distribution  of  anaesthesia.  Area  in 
lines=total  anaesthesia  and  analgesia.  Dotted  areas 
analgesia  only. 


25(5  DISEASES   OF   THE   NERVOUS   SYSTEM. 

leeches  or  wet  cups  should  be  applied  to  the  spine,  diaphoresis 
should  be  promoted,  small  doses  of  aconite  and  nitroglycerin  should 
be  given,  and  a  calomel  purge  administered.  The  bladder  should 
be  "watched.  After  a  week,  moderate  doses  of  iodide  of  potassium 
should  be  given.  After  about  three  weeks,  if  there  is  no  fever, 
electricity  may  be  applied  carefully  and  strychnine  administered  in 
small  doses.  Bed-sores  should  be  guarded  against  by  the  use  of 
water  beds  or  cushions,  absorbent  cotton,  bathing  the  parts  with 
alcohol  and  weak  solutions  of  tannku  Infusion  of  buchu,  boric 
acid,  and  tincture  of  hyoscyamus  will  often  help  the  bladder  disturb- 
ance. The  frequency  of  syphilis  as  a  cause  of  myelitis  (nearly 
one- half  the  cases)  should  lead  to  the  persistent  use  of  mercurial  in- 
unctions and  of  iodide  for  a  long  time.  After  acute  symptoms  sub- 
side, tonics  such  as  arsenic,  iron,  and  strychnine  in  small  doses  may 
be  given.  Suspension  may  be  tried  carefully;  mechanical  ap- 
pliances may  be  used  to  help  the  rigid  limbs;  lukewarm  baths, 
douches,  and  massage  are  helpful  to  some  extent. 

Chronic  Myelitis    (including   Transverse,  Diffuse,   Dissemi- 
nated, and  Compression  Myelitis). 

Chronic  meylitis  is  the  name  given  to  a  disease  characterized 
by  a  chronic  inflammation  of  the  spinal  cord  and  to  the  chronic  re- 
parative processes  which  follow  acute  inflammation,  injury,  and 
softening.  Chronic  myelitis  is  usually  a  mixture  of  inflammatory, 
reparative,  and  necrotic  processes. 

Forms. — Different  names  are  given  to  chronic  myelitis  in  accord- 
ance with  the  part  of  the  cord  affected.  Usually  the  disease  affects 
only  certain  levels,  and  then  it  is  called  transverse  myelitis.  More 
rarely  it  is  diffuse  or  disseminated,  central  or  marginal.  When 
caused  by  pressure  from  vertebral  disease,  it  is  called  compression 
myelitis. 

Etiology. — The  disease  may  be  either  'primary  or  secondary. 
The  primary  form  is  somewhat  rarer.  It  occurs  chiefly  in  adults 
and  in  early  and  middle  life,  and  much  oftener  in  males.  Expo- 
sure, shocks,  infectious  fevers,  lead,  and  syphilis  are  the  chief 
causes,  but  above  all  syphilis.  Syphilis  causes  it  by  producing 
arterial  disease  and  by  setting  up  a  specific  inflammatory  infiltra- 
tion. Seeondwry  chronic  myelitis  is  a  rather  common  form.  It  is 
really  only  the  later  stage  of  acute  myelitis,  softening,  hemorrhage, 
or  injury. 

Meningitis  may  extend  and  cause  a  meningo-myelitis.  A  neu- 
ritis may  possibly  ascend  and  cause  myelitis,  but  such  cases,  if  they 
occur,  are  very  rare.     Compression  myelitis  is  usually  a  slowly  de- 


MYELITIS INFLAMMATION    OF   THE   SPINAL   CORD.  257 

structive,  not  an  inflammatory  process,  and  it  begins  as  a  meningitis 
of  the  dura  mater. 

Among  67  personal  cases  there  -were  61  men  and  6  women.  The 
causes  that  can  be  assigned  were :  Syphilis  23;  injuries  12;  ex- 
posure 3;  acute  infection  6,  of  which  3  followed  grippe,  1  typhoid 
and  1  meningitis,  1  mumps.  Two  were  due  to  caisson  disease;  -1 
were  of  arterio-sclerotic  origin  occurring  in  the  aged,  and  6  were 
due  to  tuberculosis.  A  study  of  the  age  shows  that  in  the  decade 
between  thirty-one  and  forty  there  were  23  cases;  twenty-one  and 
thirty,  14  cases;  forty -one  and  fifty,  16  cases;  fifty-one  and  sixty- 
four,  73  cases;  eleven  and  twenty,  2;  under  ten,  2.  Practically  all 
the  cases  occur  between  the  ages  of  twenty-one  and  fifty,  and  most 
of  them  between  the  ages  of  thirty-one  and  forty.  Those  cases  occur- 
ring in  the  extreme  of  life  are  due  to  senile  arterial  changes  or  to 
tubercle  or  injury.  There  is  not  much  difference  in  the  age  re- 
lations of  the  cases  of  syphilitic  origin  and  those  due  to  other  causes. 
Between  twenty -one  and  thirty,  5  out  of  14  were  of  syphilitic 
origin.  Between  thirty-one  and  forty,  9  out  of  23  were  of  specific 
origin,  and  syphilis  may  fairly  be  said  to  cause  over  one-half  the 
eases  of  non-traumatic  and  non-tuberculous  myelitis  of  adult  life. 

Symptoms. — "When  the  disease  begins  primarily  as  a  chronic 
affection  the  symptoms  are  as  given  below.  And  since  nearly  all  the 
eases  are  of  syphilitic  origin,  the  description  of  primary  chronic 
myelitis  is  practically  that  of  syphilitic  spinal  paralysis. 

The  patient  notices  that  his  legs  seem  heavy  and  easily  get  tired; 
prickling  andmuiili  sensations  are  felt  in  the  feet;  occasionally  a  lit- 
tle pain  develops  in  the  back  or  there  is  a  sense  of  constriction  about 
the  trunk.  The  Legs  are  stiff,  and  tests  often  show  that  the  reflexes 
are  exaggerated,  with  ankle  clonus  and  flexor  response  (sign  <>f  Ba- 
binski).  There  is  but  little  wasting  of  them,  however.  The  sexual 
power  declines;  the  bladder  gives  some  trouble,  there  being  a  ten- 
dency to  retention;  the  bowels  are  constipated.  After  a  few  weeks 
or  months  there  is  a  partial  paraplegia,  with  rigidity  of  the  limbs 
and  e:  ed    reflexes.     Some  anaesthesia  exists,  and  occasional 

pain,  which  is  not  severe  and  is  felt  more  in  the  back  than  the  legs. 

The  muscles  have  now  wasted  somewhat,  but  show  no  decided 
changes  to  the  electrical  current.  The  bladder  becomes  more  in- 
volved, the  urine  has  to  be  drawn,  it  is  often  alkaline,  ami  unless 
care  is  taken  cystitis  develops.  The  patient  is  still  able  to  walk, 
but  he  does  so  with  a  stiff,  shuffling  gait  which  is  characteristic 
(Fig.  118 y.  The  disease  may  show  signs  of  slowly  extending  up  and 
down,  more  often  up.  The  arms  become  involved;  weakness  and 
stiffness,  with  some  wasting,  anaesthesia,  and  pain,  develop,  or  the 
disease  may  cease  its  progress  and  the  patient  remain  partly  para- 
lyzed for  years.  The  general  health  during  the  course  of  the  disease 
17 


258 


DISEASES    OE   THE    NERVOUS    SYSTEM. 


deteriorates  slowly ;  the  patients  often  become  anaemic  and  have  an 
unhealthy  pallor.  Eventually  the  paraplegia  becomes  complete,  the 
patient  is  bedridden,  the  legs  are  atrophied,  contractured,  and  rigid, 
with  more  or  less  anaesthesia.  Cystitis  and  nephritis  develop,  and 
the  patient  dies  from  these  or  other  intercurrent  diseases. 

Chronic  secondary  myelitis,  which  is  the  form  often  seen,  pre- 
sents eventually  much  the  same  picture  as  that  just  described.     In 

this  type,  however,  the  symptoms  are 
worse  at  first,  then  improve  or  regress, 
then  become  stationary,  and  finally  grow 
worse. 

Symjjtoms  of  the  Different  Forms. — 
The  usual  type  of  chronic  myelitis  is 
the  transverse  dorsal  or  dorso-lumbar, 
and  this  gives  symptoms  as  above  de- 
scribed. It  is,  as  stated,  usually  a  syphi- 
litic spinal  disease.  If  the  lumbar  region 
is  affected  there  are  more  paraplegia, 
wasting,  and  involvement  of  organic  cen- 
tres. If  the  myelitis  is  cervical  -the 
arms  are  involved,  there  may  be  pupil- 
lary changes,  and  the  respiratory  muscles 
are  partly  paralyzed;  the  paraplegia  is 
not  so  complete  and  the  disturbances  of 
sensation  are  likely  to  be  more  varied. 

Conijyvession  myelitis,  so  called,  is 
usually  only  a  compression  atrophy.  It 
is  due,  as  a  rule,  to  vertebral  caries,  but 
its  cause  may  be  a  spinal  tumor,  aneur- 
ism, and  pachymeningitis.  Compression 
myelitis  is  distinguished  from  other  forms 
by  its  slow  onset  and  the  presence  at  first  of  irritative  or  "  root " 
symptoms.  The  patient  suffers  from  pain  and  tenderness  localized 
at  a  certain  point  in  the  spine.  The  pain  radiates  about  the  trunk 
or  down  the  limbs  and  is  increased  on  movements.  At  about  the 
same  time  some  motor  weakness  develops,  usually  in  the  form  of 
paraplegia.  The  muscles  waste  but  slightly.  The  reflexes  are  ex- 
aggerated; twitchings,  spasms,  and  contractures  finally  occur,  and 
there  is  developed  a  spastic  paraplegia  or  quadruplegia.  With 
this  there  is  usually  some  anaesthesia,  though  it  is  not  complete. 
The  disease  is  oftenest  in  the  dorsal  or  lower  cervical  region,  and 
hence  the  sphincters  escape  until  late.  Locally,  evidences  of  spine 
disease  appear  early  in  the  form  of  a  kyphosis. 

A  central  or  peri-ependymal  myelitis  can  rarely  be  recognized  with 


Fig.  118.— Attitude  in  Chronic 
Myelitis. 


MYELITIS — INFLAMMATION    OF   THE   SPINAL    CORD.  259 

certainty.  It  produces  less  pain  and  irritation,  but  leads  to  mus- 
cular atrophy,  disorders  of  sensations  such  as  thernio-anaesthesia, 
disturbance  of  vasomotor  and  secretory  nerves  and  visceral  centres. 

Pathology. — The  pia  mater  is  thickened  over  the  affected  region 
and  often  throughout  the  cord.  The  cord  itself  has  a  gray,  dis- 
colored look  at  the  affected  level,  and  is  usually  shrunken  or  dis- 
torted and  hard  to  the  touch.  In  severe  cases  of  secondary  char- 
acter it  is  reduced  to  a  small  size,  and  the  membranes  about  it  are 
thick  and  inflamed.  In  transverse  myelitis  a  vertical  area  of  only 
two  or  three  inches  is  involved.  The  microscope  shows  that  the 
prominent  changes  are  loss  of  nerve  structure,  great  increase  of  con- 
nective tissue,  and  increase  in  the  number  of  vessels,  which  often 
have  thickened  walls.  In  the  more  seriously  diseased  part  little  is 
seen  but  connective  tissue.  In  parts  less  diseased  some  nerve  fibres 
are  seen,  many  having  evidences  of  partial  disintegration.  There 
is  also  a  good  deal  of  amorphous  material  studded  with  nuclei. 
Stellate  cells,  granule  cells,  and  nerve  cells  in  various  stages  of 
degeneration  are  present.  In  the  parts  less  affected  the  signs  of 
congestion  and  vascular  irritation  are  more  pronounced. 

Diagnosis. — This  must  be  made  from  progressive  muscular 
atrophy  and  amyotrophic  lateral  sclerosis,  pachymeningitis  and 
spinal  tumor;  from  locomotor  ataxia,  multiple  sclerosis,  and  brain 
palsies. 

In  progressive  muscular  atrophy  there  is  a  peculiar  atrophy  with- 
out involvement  of  the  sphincters  or  sensory  disturbance.  In 
pachymeningitis  there  is  often  a  history  of  an  injury;  there  is  more 
pain  in  the  back  and  a  more  marked  anaesthesia.  The  sphincters 
are  not  involved.  Pachymeningitis  is  also  usually  located  in  the 
cervical  region.  Tumors  usually  cause  much  more  pain;  the  symp- 
toms come  on  slowly  and  are  more  definitely  localized.  A  spastic 
paraplegia  occurs  from  brain  disease  and  as  a  functional  trouble. 
In  either  case  there  are  no  trophic  or  sensory  troubles,  nor  is  there 
involvement  of  the  sphincters.  In  locomotor  ataxia  there  is  no 
great  degree  of  motor  paralysis,  and  there  are  peculiar  ataxic  and 
sensory  disturbances.  In  multiple  sclerosis  there  are  eye  symptoms, 
speech  disturbances,  and  tremor.  Paralysis  from  brain  disease  is 
almost  always  unilateral,  painless,  spastic,  and  free  from  disturb- 
ance of  the  visceral  centres. 

"Prognosis. — Inflammatory  processes  have  a  tendency  to  01 
when  their  reparatory  and  eliminative  work  is  done.  Chronic  mye- 
litis, however,  is  often,  as  has  been  stated,  a  destructive  process 
due  to  some  defect  in  vascular  supply  or  to  some  mechanical  irrita- 
tion. Besides  this,  in  the  spinal  cord  secondary  degenerations  Bet 
in  as  soon  as  certain  tracts  are  interfered   with.     Hence   chronio 


260  DISEASES    OF    THE    NERVOUS   SYSTEM. 

myelitis,  after  a  period  of  improvement,  generally  progresses,  and 
the  prognosis  is  not  very  favorable.  Still,  patients  may  live  from 
five  to  tweny-five  years.  Dorsal  myelitis  is  the  most  favorable 
form;  compression  myelitis  from  caries  can  also  often  be  success- 
fully treated.  Those  forms  which  come  on  rather  rapidly  are  more 
likely  to  cease  progressing  (Gowers) .  Serious  involvement  of  the 
bladder  is  a  bad  sign,  and  naturally  the  prognosis  is  worse  the  more 
complete  the  paralysis. 

Treatment. — In  the  earlier  and  progressive  stage  of  chronic  mye- 
litis rest  is  imperative.  The  patient  should  lie  down  much  of  the 
time.  Counter-irritation  in  the  form  of  fly  blisters,  the  cautery,  or 
setons  should  be  applied,  and  if  no  improvement  results  wet  or  dry 
cups  used.  The  descending  galvanic  current  along  the  spine  should 
be  tried;  faradism  and  massage  being  used  upon  the  limbs.  Cold 
baths  and  cold  applications  must  be  prescribed  carefully  if  at  all. 
Lukewarm  baths,  90°  to  98°  F.,  or  half -baths  with  friction  at  70 J  to 
80°  F.,  are  more  likely  to  be  useful,  but  even  these  must  be  tried 
cautiously.  The  first  baths  should  last  not  over  five  minutes  and 
should  be  repeated  only  three  or  four  times  weekly.  In  later  para- 
plegic and  bedridden  stages,  electrical  and  hydro-therapeutic  appli- 
cations should  be  followed  up  patiently  and  persistently.  The  pa- 
tient now  may  be  allowed  to  remain  and  exercise  in  the  lukewarm 
bath  for  some  time. 

Internally,  iodide  of  potassium  and  mercury  should  be  first 
given.  After  thorough  trial  with  these  remedies  for  six  or  eight 
weeks,  the  patient  should  be  given  courses  of  treatment  with 
arsenic,  nitrate  of  silver,  phosphorus,  and  perhaps  the  chloride  of 
gold.  Pills  of  arsenite  of  sodium,  gr.  -£w,  may  be  administered  three 
or  four  times  daily  for  two  months ;  if  benefit  ensues,  the  remedy 
should  be  resumed  after  an  intermission  of  three  weeks.  Phos- 
phorus is  best  given  in  the  form  of  an  elixir  in  doses  of  gr.  J*  ter 
in  die  increased  to  gr.  T1¥.  The  remedy  should  be  suspended  for 
three  days  at  the  end  of  each  ten  days.  Silver  is  given  usually 
in  the  form  of  the  nitrate  (dose,  gr.  i  to  -^).  Not  more  than  one 
drachm  should  be  given  without  a  three-months'  intermission. 
Some  assert  that  the  hypophosphite  of  silver  and  sodium,  and 
the  albuminate,  are  surer  preparations.  I  do  not  advise  the 
use  of  ergot.  Strychnine  in  small  doses  is  sometimes  useful. 
Por  the  bladder  troubles,  the  internal  use  of  boric  acid,  buchu, 
sandalwood,  and  similar  drugs  is  useful.  Mechanical  and  surgical 
measures  may  be  of  some  help.  In  some  cases  suspension  does 
good,  but  it  may  do  harm.  Tenotomy  is  justifiable  for  the  purpose 
of  straightening  contractured  limbs.     In  compression  myelitis  sus- 


MYELITIS — INFLAMMATION    OF   THE   SPINAL   CORD.  261 

pension  on  an  inclined  plane  and  the  plaster  jacket  or  other  support 
are  indicated.  Cases  have  been  reported  in  which  surgical  opera- 
tions for  the  relief  of  a  supposed  tumor  have  cured  compression 
myelitis  from  Pott's  disease.  Sea  voyages  are  often  useful  and  are 
preferable  to  mountain  climates.  Rest,  quiet,  fresh  air,  and  a  very 
regular  life  are  the  essentials  in  all  climates. 

Acute  Anterior  Poliomyelitis  (Infantile  Spinal   Paralysis, 
Acute  Atrophic  Paralysis). 

Anterior  poliomyelitis  is  a  disease  of  the  spinal  cord  character- 
ized by  a  motor  paralysis  of  rapid  onset,  followed  by  muscular  wast- 
ing, without  sensory  symptoms.  It  occurs  at  all  ages,  bat  vastly 
oftener  in  infancy;  hence  it  is  often  called  infantile  spinal  palsy. 

Etiology. — The  average  age  at  the  time  of  attack  is  two  years. 
Most  cases  occur  under  ten,  and  four-fifths  of  these  occur  under 
three.  It  may  be  congenital,  i.e.,  occur  in  intra-uterine  life 
(Sinkler),  and  it  may  occur  as  late  as  sixty.  Most  adult  cases  occur 
under  the  age  of  thirty.*  Rather  more  of  the  infantile  cases  occur 
in  boys,  and  most  of  the  adult  cases  occur  in  males.  Race  and  cli- 
mate afford  no  exemption  so  far  as  is  known.  The  great  majority 
of  cases  occur  during  the  hot  months  of  summer  (Sinkler).  Nearly 
eighty  per  cent  (78.8)  occur  between  June  and  September,  inclusive. 
Heredity  has  an  influence  in  only  one  or  two  per  cent  of  cases. 

Over-exercise  and  chilling  of  the  body  when  heated  are  occa- 
sional causes.  Infectious  fevers  (oftenest  measles)  precede  the  at- 
tack  in  about  seven  per  cent  (Sinkler).  The  disease  has  several 
times  occurred  as  an  epidemic.  Dentition  is  rarely  an  excit- 
ing cause,  as  used  to  be  supposed.  Injuries  and  falls  in  a  few 
instances  appear  to  be  the  cause  of  the  disease.  The  fact  that  the 
ehilil  is  just  beginning  to  walk  at  the  period  when  most  susceptible 
to  poliomyelitis  must  be  considered  of  importance,  since  the  new 
movements  call  for  an  unusual  activity  of  the  spinal  centres. 

To  sum  up,  aye,  season,  and  infectious  diseases  are  the  three  most 
important  etiological  factors. 

Symptoms. — There  are  rarely  any  premonitory  symptoms.     The 

*  Among  50  personal  cases,  '■)'■)  were  in  children.  Of  the  latter  there  were- 
24  males,  15  females.  Ages:  Under  six  months,  1;  half  to  one  year,  8 ;  one 
to  two  years,  10;  two  to  three;  years,  5 ;  three  to  four  years,  :! ;  four  to  six 
years,  ?,\  six  to  eight  years,  8.  Final  result  was  palsy,  chiefly  in  right  leg, 
in  14 ;  chiefly  in  left  leg,  in  5 ;  in  both  Vi^s,  ."i ;  in  right  arm,  4  ;  all  four  ex- 
tremities, 1 ;  the  remainder  in  various  combinations.  Disease  followed 
scarlatina  in  1,  pertussis  in  2,  cholera  Infantum  in  1,  some  "fever"  in  nearly 
all  cases. 


262  DISEASES   OP   THE    NERVOUS    SYSTEM. 

patient  is  taken  with  a  slight  fever,  100°  to  102°  F.,  accompanied 
by  vomiting,  diarrhoea,  or  convulsions.  In  a  few  hours  or  a  clay 
paralysis  develops ;  sometimes  the  paralysis  is  as  much  as  a  week  in 
developing  ("subacute  form").  The  fever  lasts  from  one  to  three 
or  four  days.  The  paralysis  rapidly  reaches  its  height,  then  remains 
stationary  for  a  time;  then  improvement  sets  in,  which  reaches  a 
certain  point  and  stops. 
We  have  consequently : 

1.  A  stage  of  invasion — a  few  hours  or  a  week. 

2.  A  stationary  period — one  to  six  weeks,  usually  two  weeks. 

3.  A  stage  of  improvement — six  months  to  a  year. 

4.  A  chronic  stage. 

1.  The  stage  of  invasion  may  be  so  sudden  as  to  suggest  hemor- 
rhage. Sometimes  the  child,  after  a  restless,  feverish  night,  wakes 
in  the  morning  paralyzed.  Usually  the  initiatory  symptoms  last 
less  than  a  day.  With  or  before  the  paralysis  a  fever  of  100°  to 
102°  F.,  vomiting,  delirium,  and,  much  less  often,  convulsions 
which  are  not  severe,  occur.  After  the  general  disturbance  subsides 
there  may  be  some  pain  in  the  back  and  limbs  for  a  few  days,  and 
in  rare  cases  the  bladder  is  involved  so  that  there  is  retention  of 
urine.     But  the  dominant  symptom  is  motor  paralysis. 

The  paralysis  is  oftenest  paraplegia,  next  one  leg,  next  the  arms 
and  legs,  and  after  this  various  combinations.  The  eye  muscles, 
laryngeal  and  respiratory  muscles,  always  escape  in  infants.  In 
older  persons  the  facial  nerve  may  be  involved.  In  certain  peculiar 
cases  the  cranial  nerve  nuclei  are  attacked,  in  association  with  the 
anterior  horns.  When  the  eye-muscle  nuclei  are  involved  it  is  called 
"  polio-encephalitis  superior ;"  when  cranial  nerve  nuclei  lower  down 
are  involved  it  is  called  "  polio-encephalitis  inferior." 

2.  The  paralysis  reaches  its  height  in  from  one  to  four  days. 
It  remains  at  its  height  for  from  one  to  six  weeks,  and  then  im- 
provement gradually  sets  in.  In  two  or  three  weeks  a  wasting  of 
the  paralyzed  limb  may  be  noticed.  It  is  flabby,  its  temperature 
lowered,  and  the  reflexes  are  gone.  Slight  tenderness  may  be 
present,  but  there  is  no  anaesthesia. 

3.  The  stage  of  improvement  lasts  for  from  six  to  twelve  months. 
There  is  gradual  disappearance  of  the  paralysis,  beginning  in  the 
limbs  least  affected.  This  continues  until  the  paralysis  has  left  all 
but  one  or  two  limbs.  As  a  rule,  it  is  the  legs  alone  that  are  finally 
left  paralyzed.  In  a  quarter  of  the  cases  both  legs,  and  in  half  of 
the  cases  one  leg,  oftener  the  right,  remain  affected.  The  muscles 
waste  and  show  the  reaction  of  degeneration,  viz.,  loss  of  faradic  ir- 
ritability, retention  but  lessening  of  galvanic  irritability,  sluggish 


MYELITIS — INFLAMMATION    OF   THE   SPINAL   COED. 


263 


contractions,  and  sometimes  polar  changes.  In  the  leg  the  anterior 
tibial  group  of  muscles  is  oftenest  affected,  in  the  arm  the  deltoid 
and  shoulder  group.  The  atrophy,  having  reached  a  certain  grade, 
finally  ceases,  and  then  a  slight  improvement  may  set  in.  After 
the  end  of  a  year  not  much  further  spontaneous  improvement  can 
be  expected. 

4.  The  temperature  of  the  affected  limb  is  lowered  several  de- 
grees, the  skin  has  a  reddish-purplish,  mottled  look.  The  bones  as 
well  as  muscles  of  the  affected  limbs  do  not  grow  so  fast  as  those  of 
the  healthy  limb.  Hence  in  time  the  foot  becomes  smaller  and  the 
leg  shorter.  Owing  to  the  contraction  of  unopposed  muscles  de- 
formities occur.     The  most  frequent  are   talipes   equinus,  talipes 


Fig.  119. 


Fig.  120. 


Vm.  1 19.  —Anterior  Poliomyelitis  in  Lumbar  Segment  (Demaschino). 
Fig.  130.— Same,  Much  Enlarged,  showing  congestion. 

valgus  and  varus.  Deformities  of  the  knees,  contraction  of  the 
plantar  fascia,  and  lateral  curvature  of  the  spine,  also  take  place. 
The  general  health  of  the  patient  is  usually  good. 

l'titlwlocjy. — The  disease  is  an  acute  exudative  inflammation  with 
destruction  of  tissue,  but  without  suppuration.  It  affects  chiefly 
the  anterior  cornua,  especially  of  the  lumbar  and  cervical  enlarge- 
ments (Figs.  119,  120).  It  is  not,  as  a  rule,  diffuse,  but  often  the 
brunt  of  the  trouble  is  felt  only  by  certain  cell  groups.  These  are 
destroyed,  and  after  a  time  connective  tissue  takes  their  place.  In 
rare  cases  the  larger  part  of  the  central  gray  and  some  of  the  white 
matter  are  involved.  Later  a  certain  amount  of  sclerosis  occurs  in 
the  lateral  columns.  The  anterior  roots  and  motor  nerves  atrophy. 
The  muscle  tissue  also  wastes,  and  its  place  is  supplied  by  connec- 
tive tissue. 

Diagnosis — The  disease  must  be  distinguished  from  multiple 
neuritis,  spinal  hemorrhage,  cerebral  palsies,  birth  palsies,  and  pro- 


264  DISEASES   OF   THE    NERVOUS   SYSTEM. 

gressive  muscular  atrophy.     The  diagnosis  can  be  easily  made  in 
almost  all  cases  by  remembering  these  facts : 

1.  The  age  of  the  patient. 

2.  The  abrupt  onset  and  rapid  development  of  extreme  paralysis. 

3.  The  tendency  to  improve. 

4.  The  absence  of  anaesthesia,  bladder  or  rectal  symptoms, 
rigidity,  and  pain. 

5.  The  electrical  reactions. 

6.  The  arrest  of  growth  of  the  limb.  Multiple  neuritis  and 
progressive  muscular  atrophy  rarely  occur  in  children.  Myelitis 
and  hemorrhage  are  usually  accompanied  by  sensory  disorders,  bed- 
sores, and  bladder  troubles ;  cerebral  palsies  are  usually  unilateral 
and  accompanied  by  symptoms  of  stiffness  and  exaggeration  of 
reflexes. 

Prognosis. — The  patient  rarely  dies,  either  from  the  disease  or 
its  sequelae.  He  always  improves,  but  he  hardly  ever  gets  entirely 
well.  The  cases  in  which  recovery  is  complete  are  those  of  simple 
exudative  inflammation  without  any  necrosis.  Much  can  be  done 
by  careful  and  persistent  treatment  and  by  the  help  of  orthopaedic 
surgery,  even  in  old  cases.  The  usual  course  is  for  the  patient  to 
get  back  the  use  of  all  but  one  leg.  He  grows  to  adult  life  with 
this  short  and  weakened  member. 

Treatment. — In  the  acute  stage  the  child  should  be  put  to  bed 
and  kept  there.  Iodine  or  mustard  plasters  or  leeches  must  be  ap- 
plied to  the  spine.  Internally,  a  smart  laxative  and  a  diuretic  must 
be  given  (calomel,  gr.  iij.;  tartrat.  potas.,  gr.  xx.).  Then  tincture. 
of  aconite  is  to  be  administered  in  doses  of  one  drop  every  half-hour 
as  indicated  by  the  fever.  To  this  may  be  added  sweet  spirits  of 
nitre.  Best  is  the  most  essential  thing.  The  limbs  should  be  kept 
quiet  and  warm.  At  the  end  of  two  weeks  electrical  applications 
may  be  very  cautiously  made  to  the  limbs  three  times  a  week,  if 
there,  is  no  tenderness  or  fever.  After  four  weeks,  electrical  treat- 
ment should  be  given  daily  for  a  month,  each  limb  being  treated  for 
only  two  or  three  minutes.  After  a  rest  of  a  fortnight  another  four- 
weeks'  treatment  may  be  given.  Treatment  should  be  thus  applied 
intermittently  till  the  end  of  a  year.  After  this  it  can  be  continued 
or  stopped  according  to  the  condition  of  the  patient.  In  old  cases 
daily  treatment  for  one  or  two  years  will  sometimes  produce  valuable 
results  (G.  M.  Hammond).  That  form  of  electricity  which  causes 
muscular  contractions  most  easily  should  be  employed,  and  this  is 
usually  the  galvanic  current.  Massage  is  a  most  important  adjuvant 
to  electricity.  It  is  best  given  daily  for  not  over  ten  minutes  to  a 
single  limb.     It  is  imperative  also  that  the  physician  overcome  any 


MYELITIS — INFLAMMATION   OF    THE    SPINAL    CORD. 


265 


contractures  which  develop,  by  splints,  rubber  muscles,  and,  if 
necessary,  tenotomy.  Warmth  is  very  useful.  The  leg  should  be 
bandaged  in  cotton  at  night,  and,  if  necessary,  hot-water  bottles 
placed  beside  it.     Many  parents  cannot  afford  prolonged  electrical 


Fig.  121.— Case  ov  Chronic  Anterior  Poliomyelitis  in  an  Adult,  showing  the  wasted 

hand  and  drop  foot. 


ami  massage  treatment.  In  such  cases  they  should  be  told  to  rub 
the  limb  twice  daily  with  a  stimulating  liniment  and  wrap  it  in 
cotton  or  hot  flannels  at  night. 

The  child  should  be  taught  to  walk  and  exercise  the  limb  as 
much  as  possible.  Tricycles  and  gymnastic  apparatus  may  often  be 
brought  into  use. 

Medicines  are  of  little  value  in  the  chronic  stage.  Phosphorus, 
strychnine,  iron,  arsenic,   cod-liver   oil,    physostigma,    have    been 


2G6  DISEASES   OF   THE   NERVOUS   SYSTEM. 

recommended  and  are  sometimes  prescribed  for  the  improvement  of 
the  general  health  and  solatii  causa. 

Chronic  Anterior  Poliomyelitis. — This  form  of  myelitis  is 
very  rare,  and  most  careful  examination  must  be  made  to  exclude  on 
the  one  hand  multiple  neuritis,  and  on  the  other  progressive  mus- 
cular atrophy. 

Etiology. — Adults  are  chiefly  affected,  and  men  more  often  than 
women.  Exposure,  lead-poisoning,  and  syphilis  are  among  the 
principal  causes. 

Symptoms. — The  disease  affects  one  or  more  of  the  extremities, 
often  all  four  of  them.  There  is  a  gradual  paralysis,  rapidly  fol- 
lowed by  atrophy,  with  degenerative  electrical  reactions.  There  is 
but  little  pain  or  other  sensory  disturbance.  The  sphincters  are  not 
affected. 

The  disease  takes  one  of  two  courses  .• 

1.  After  reaching  its  height,  improvement  gradually  sets  in  and 
recovery  may  become  nearly  complete. 

2.  The  disease  steadily  progresses  until  the  patient  presents  the 
picture  of  a  case  of  progressive  muscular  atrophy.  In  a  few  months, 
or  at  the  most  one  or  two  years,  death  ensues.  Occasionally,  how- 
ever, after  reaching  a  very  advanced  stage,  the  process  stops  (Fig. 
123)  and  a  slight  improvement  may  set  in.  These  progressive  cases 
of  chronic  poliomyelitis  appear  to  stand  half-way  between  ordinary 
chronic  poliomyelitis  and  progressive  muscular  atrophy.* 

Diagnosis. — The  disease  is  distinguished  from  multiple  neuritis 
by  the  absence  of  pain,  tenderness,  and  anaesthesia;  from  progres- 
sive muscular  atrophy  by  the  rapid  onset,  the  occurrence  of  paraly- 
sis first  and  wasting  afterward,  the  early  degenerative  reactions,  and 
the  absence  of  fibrillary  contractions.  A  history  of  lead  poisoning 
may  also  help  in  the  diagnosis. 

The  treatment  is  mainly  symptomatic  and  must  be  carried  out 
on  the  lines  indicated  under  the  head  of  Acute  Anterior  Poliomye- 
litis. Iodide  of  potassium,  mercury,  and  strychnine  should  be 
given. 

Acute  and  Chronic  Senile  Paraplegia. 

A  rather  sudden  paralysis  of  both  legs  sometimes  attacks  old 
people  as  the  result  of  thrombosis  or  hemorrhage  of  spinal  arteries. 
In  these  cases  the  symptoms  come  on  suddenly,  as  in  acute  mye- 

*  Subacute  Spinal  Paralysis  of  Duchenne. — The  diseases  described  under 
this  head  are  chiefly  cases  of  multiple  neuritis.  In  a  very  few  there  are  both 
neuritis  and  myelitis ;  in  others  the  condition  is  one  of  minute  focal  spinal 
hemorrhages  with  secondary  myelitis. 


MYELITIS — INFLAMMATION   OF   THE    SPINAL   CORD.  267 

litis,  only  there  is  not  much  pain.  The  patient  has  sometimes  a 
decided  paralysis,  and  sometimes  moderate  paralysis  but  very  great 
ataxia,  depending  on  the  arteries  involved,  whether  postero-iateral 
or  central.  The  patient  usually  improves  rather  rapidly  and  may 
regain  a  large  part  of  his  strength,  but  relapse  is  likely  to  occur. 
Rest  and  proper  attention  to  diet  and  elimination  are  indicated. 

A  chronic  form  of  paraplegia,  slowly  developing,  is  also  seen  in 
old  people.  It  begins  with  simple  weakness  of  the  legs,  followed 
by  wasting  and  progressive  development  of  a  paraplegia.  The 
sphincters  eventually  become  involved.  The  disease  affects  the 
lower  extremities  first,  but  gradually  extends,  and  finally  involves 
the  arms.  The  general  characters  are  those  of  a  progressive  mus- 
cular atrophy ;  but  the  disease  is  distinguished  from  this  by  the  fact 
that  the  sphincters  become  rather  early  involved,  and  that  the  pa- 
ralysis and  wasting  go  on  together  without  any  fibrillary  contrac- 
tions. The  medulla  and  the  facial  and  ocular  muscles  do  not  become 
involved.  Clinically  the  disease  cannot  be  distinguished  from  a 
chronic  anterior  poliomyelitis  which  takes  upon  itself  a  progressive 
type.  On  post-mortem,  however,  it  is  found  that  there  is  a  soften- 
ing of  the  gray  matter  in  the  anterior  horns  of  the  spinal  cord,  more 
marked  in  the  lumbar  swelling.  This  softening  is  apparently  due 
to  the  thickening  and  obliteration  of  the  blood-vessels  from  senile 
changes  in  them. 

Dr.  Gowers  describes  a  disease  which  he  calls  senile  para- 
plegia in  which  there  are  simple  weakness  of  the  legs  and  slow- 
ness of  movement,  without  any  atrophy,  sensory  disturbance,  or 
alteration  in  the  reflexes.  He  considers  it  to  be  a  form  of  paralysis 
agitans.  The  disease  which  I  have  described,  however,  represents 
more  truly  a  simple  senile  paraplegia.  Very  little  can  be  done  for 
this  trouble  therapeutically.  The  use  of  nitroglycerin,  iodide  of 
potassium,  sparteine,  digitalis,  and  general  tonic  and  hygienic 
measures  are  indicated. 

Acute  Ascending  Paralysis  (Landry's  Paralysis). 

Acute  ascending  paralysis  is  a  disease  characterized  by  a  rapidly 
developing  paralysis  which  begins  in  the  legs  and  then  involves  in 
turn  the  trunk,  arms,  respiratory  and  throat  muscles,  usually  end- 
ing in  death.  There  is  little  disturbance  of  sensation,  no  atrophy 
or  changes  in  electrical  irritability,  and  no  involvement  of  the 
sphincters. 

Etiology. — The  disease  is  a  rare  one.  It  occurs  chiefly  between 
the  ages  of  twenty  and  forty  j  men  are  affected  oftener  than  women. 


268  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Exposure  is  an  exciting  cause,  and  it  occurs  sometimes  after  acute 
infectious  fevers  and  syphilis.  The  form  of  rabies  known  as  "  para- 
lytic" causes  a  disease  which  is  apparently  identical  with  Landry's 
paralysis. 

Symptoms. — There  may  be  slight  premonitory  symptoms  for  a 
few  days,  consisting  of  numbness  iu  the  extremities,  pain  in  the 
back  or  limbs,  and  malaise.  The  first  definite  sign  of  the  disease  ia 
weakness  in  the  legs,  which  rapidly  increases  until  in  a  day  or  two 
the  patient  cannot  walk.  The  paralysis  soou  involves  the  arms  and 
then  the  muscles  of  respiration;  the  medulla  is  last  affected,  and 
then  respiration  becomes  difficult;  swallowing  aud  articulation  may 
be  impossible.  In  rare  cases  there  are  facial  and  eye  palsies.  Dur- 
ing the  course  of  the  paralysis  there  is  little  pain  or  sensory  disturb- 
ance, but  some  degree  of  anaesthesia  may  occur.  The  deep  reflexes 
are  abolished.  There  are  no  vasomotor  and  no  secretory  disturb- 
ances, no  noticeable  atrophy,  and  no  degenerative  reactions  in  the 
affected  muscles.  The  bladder  and  rectum  are  involved  only  in  rare 
cases.  There  may  be  slight  initial  fever,  but  none  occurs  after  the 
disease  has  well  set  in.     The  mind  remains  clear. 

The  disease,  as  a  rule,  ends  fatally,  and  it  usually  runs  its  course 
in  less  than  a  week.  Death  has  occurred  in  forty-eight  hours.  On 
the  other  hand,  death  has  been  postponed  three  or  four  weeks. 

In  other  cases  the  disease  stops  short  of  the  medulla.  The  pa- 
tient becomes  totally  or  nearly  paralyzed  below  the  neck.  He  then 
begins  slowly  to  improve,  and  this  improvement  continues  for  one 
or  two  years.     Eventually  a  fair  degree  of  health  is  obtained. 

Variations. — The  disease  has  been  known  to  begin  in  the  medulla 
or  cervical  region  and  descend. 

Pathological  Anatomy. — A  number  of  different  diseases  have 
been  described  under  the  head  of  Landry's  paralysis,  and  corre- 
spondingly a  number  of  different  anatomical  changes  have  been 
found.  Multiple  neuritis,  acute  diffuse  myelitis,  and  poliomyelitis 
existed  in  some  cases.  In  others  there  was  a  dropsical  exudation  in 
the  central  canal  of  the  spinal  cord,  or  a  hyaline  change  in  the  cen- 
tral arteries.  In  recent  years  decided  changes  in  the  anterior-horn 
cells  have  been  detected  by  means  of  the  Nissl  stain  •,  and  it  is  pretty 
well  decided  that  the  disease  is  in  its  ordinary  manifestations  an  acute 
toxaemia  of  the  peripheral  motor  neuron,  a  fulgurating  type  of  ante- 
rior poliomyelitis.  It,  however,  affects  in  some  cases  the  gray  mat- 
ter of  the  brain  also.  The  paralysis  is  probably  due  to  a  poison  of 
microbic  origin.  In  some  cases  certainly  this  poison  is  that  of 
rabies;  but  it  is  not  impossible  that  other  infections  may  pick 
out  and  suspend  the  functions  of  the  anterior  cornual  cells,  or, 


MYELITIS — INFLAMMATION    OF   THE    SPIXAL   CORD.  269 

as  Gowers  suggests,  the  "  end  brushes  "  of  the  motor  tract  which 
connect  with  these  cells.     This  would  explain  the  symptoms. 

Sometimes  the  poison  may  be  so  great  in  amount  and  so  irritat- 
ing as  to  set  up  a  myelitis  or  perhaps  a  neuritis.  Cases  illustrating 
these  facts  have  been  reported  (Eichberg,  Kosenheim,  Putnam). 
But  in  most  cases  the  patient  dies  before  the  toxin  can  produce  any 
inflammatory  reaction. 

The  prognosis  is  very  grave,  but  not  absolutely  bad.  If  there  is 
reason  to  suspect  the  case  of  being  one  of  paralytic  rabies,  no  hope 
can  be  offered. 

Diagnosis. — This  must  be  made  from  acute  poliomyelitis,  acute 
myelitis,  and  acute  multiple  neuritis. 

Its  acute  ascending  course,  absence  of  fever,  of  anaesthesia, 
atrophy,  decubitus,  sphincter  troubles,  and  especially  the  absence  of 
degenerative  electrical  reactions  are  sufficient  to  enable  one  to  make 
the  diagnosis.  The  age  of  the  patient,  and  the  presence  or  absence 
of  an  alcoholic  history  should  be  considered. 

Treatment. — This  consists  of  warm  baths  or  packs,  counter-irri- 
tation to  the  spine,  laxatives,  and  rest.  Large  doses  of  ergotin,  gr. 
ij.,  every  hour  have  been  successful  in  one  case.  Salicylate  or  ben* 
zoate  of  sodium,  iodide  of  potassium,  and  mercury  may  be  tried. 


CHAPTER  XIV. 

THE   DEGENERATIVE   DISEASES   OE  THE   SPINAL 

CORD. 


Introductory  :  The  Nature  and  Types  of  Degeneration 
and  Sclerosis. — The  degenerative  diseases  of  the  spinal  cord  are 
sometimes  called  "system  diseases/'  and  some  are  often  spoken  of 
as  scleroses.  There  are  no  true  system  diseases,  however,  except 
locomotor  ataxia,  progressive  muscular  atrophy,  and  amyotrophic 
lateral  sclerosis.  These  should  really  be  called  "neuron"  rather 
than  "  system"  diseases,  and  this  latter  term  is  best  not  used  as  a 
basis  of  classification.  The  term  "sclerosis,"  also,  is  somewhat 
misleading.  Properly  speaking  it  is  the  fibroid  (and  neuroglia) 
induration  which  results  from  degeneration,  destruction,  or  in- 
flammation of  nerve  tissue.  We  speak  of  degenerative  sclerosis, 
of  an  inflammatory  and  of  a  neuroglia  sclerosis,  or  of  a  sclerosis  of 
mixed  origin,  according  to  the  nature  of  the  primary  disease  which 
caused  it.  The  words  "  degeneration"  and  "  sclerosis"  are  often 
used  to  indicate  the  same  thing,  one  being  the  pathological  name, 
the  other  the  anatomical.  I  shall  use  the  term  "  sclerosis"  here  in 
its  pathological  sense,  meaning  the  process  of  hardening,  in  pre- 
senting a  classification  of  the  degenerations  of  the  spinal  cord. 


Spinal  scleroses 
or  degenera- 
tions. 


'  a.  Primary  and  de- 
generative. 


b.  Secondary. 


f  Posterior  spinal  sclerosis  (locomo- 
tor ataxia). 

Lateral  sclerosis. 

Combined  sclerosis. 

Progressive  muscular  atrophy, 
amyotrophic  lateral  sclerosis. 

Ascending  and  descending  degen- 
erations. 

Chronic  myelitis  and  sclerosis  fol- 
lowing destruction  of  cord. 

Multiple  sclerosis. 

A  few  words  of  explanation  are  needed  regarding  these  different 
conditions,  since  a  world  of  confusion  has  been  made  on  account  of 
the  different  standpoints  taken  by  writers  when  nerve  pathology  was 
young. 

a.  Primary  degeneration  or  primary  sclerosis,  as  one  may  say 


THE    DEGENERATIVE    DISEASES    OF   THE    SPINAL   UORD. 


271 


for  convenience,  is  a  process  which  begins  in  the  nerve  tissue  itself 
and  ends  in  its  atrophy,  with  substitution  of  connective  tissue.  As 
to  its  nature,  so  far  as  the  microscope  shows  us,  it  is  a  gradual  decay 
and  death  of  the  neurons.  In  some  sclerotic  processes,  like  loco- 
motor ataxia,  this  decay  is  accompanied  by  the  development  of 
irritating  products,  leucomains  or  toxalbumins,  which  may  pro- 
duce so  active  a  change  in  the  connective  tissue  as  to  lead  to  some- 
thing resembling  a  secondary  or  reactive    innainmatiou.     This  is 


Fig.  122. — Showing  the  Tracts  Affected  in  Secondary  Degenerations  of  the 
Spinal.  Cord  in  Lesions  at  Different  Levels.  1,  Descending  degeneration  after  lesion 
at  sixth  .ervical;  2,  ascending  and  descending  degeneration,  lesion  at  sixth  dorsal;  3, 
ascending  and  descending  degeneration,  lesion  at  twelfth  dorsal;  4,  ascending  degenera- 
don,  lesion  at  first  sacral. 


never  of  high  grade,  however,  and  in  some  forms  of  tabes  is  very 
slight. 

In  progressive  muscular  atrophy  the  decay  and  death  produce 
few  irritating  products,  though  enough,  perhaps,  to  account  for  the 
fibrillary  twitchings  and  occasional  hypertonic  condition  of  the 
muscles. 

The  ultimate  cause  of  these  degenerative  processes  is  not  known. 
The  progressive  character  of  the  diseases  like  locomotor  ataxia  and 


272  DISEASES   OF    THE    NERVOUS    SYSTEM. 

progressive  muscular  atrophy  would  lead  one  to  think  that  there  is 
a  poison  at  woi\i  and  constantly  acting  on  the  diseased  tissue.  So 
far,  all  bacteriological  examinations  have  failed  to  disclose  any 
microbe,  but  the  fact  that  many  degenerative  processes  follow  in- 
fectious fevers  or  syphilis  has  led  to  the  suggestion  that  pathogenic 
germs  have  poured  into  the  system  a  poison,  or  have  so  modified  the 
cellular  nutrition  that  there  is  a  poison  constantly  thrown  out,  which 
irritates  and  destroys  certain  areas  of  nerve  tissue.  .The  normal 
immunity  of  certain  neurons  to  metabolic  poisons  is  lost. 

All  the  primary  degenerations  or  scleroses  have  a  certain  degree 
of  kinship.  Their  causes  are  in  many  respects  the  same,  the  course 
of  all  is  uniformly  progressive,  and  one  not  very  infrequently  com- 
plicates another.  The  sharpest  distinctions  are  found  between 
those  affecting  the  peripheral  motor  neurons  and  the  peripheral  sen- 
sory neurons.  Degenerative  processes  implicating  the  former  are 
much  rarer  and  their  course  is  more  rapid  and  fatal. 

The  degenerations  of  the  spinal  ganglia  and  the  peripheral  sen- 
sory neurons  are  more  common,  slower  in  course,  different  in  etiol- 
ogy, and  much  more  varied  in  symptomatology.  Locomotor  and 
the  hereditary  ataxias  furnish  examples  of  this  type. 

b.  Secondary  Degenerations  of  the  Spinal  Cord. — When 
any  of  the  long-fibre  tracts  of  the  cord  are  cut  across  or  de- 
stroyed, there  soon  results  a  degeneration.  This  extends  up  or 
down  in  accordance  with  the  direction  in  which  the  tracts  carry  im- 
pulses. Thus,  when  the  crossed  pyramidal  tract  is  cut  across  the 
degeneration  extends  down;  when  the  column  of  Goll  is  involved  it 
extends  up.  The  degenerative  process  begins  almost  immediately 
and  is  complete  in  a  few  weeks.  The  myelin  sheath  swells,  grad- 
ually breaks  up,  and  disintegrates;  the  axis  cylinder  is  involved 
next.  At  the  same  time  the  connective  tissue  proliferates  and 
takes  the  place  of  the  wasted  nerves.  Finally,  long  tracts  of  con- 
nective tissue  have  taken  the  place  of  the  nerve  tissue.  The  proc- 
ess may  not  be  a  complete  one  if  the  lesion  does  not  entirely  de- 
stroy the  tract.  The  short-fibre  tracts  degenerate  only  a  little  way 
up  and  down. 

Secondary  degenerations  complicate  and  add  to  the  pathological 
change  in  all  organic  diseases  of  the  cord.  In  brain  disease,  involv- 
ing the  motor  tract,  as  in  hemiplegia,  secondary  degeneration 
extends  into  the  cord  and  adds  to  the  seriousness  of  the  disease. 
Degenerations  of  the  spinal  cord,  however,  do  not  extend  up  to 
the  brain  except  in  the  case  of  disease  of  the  cerebellar  tracts. 

Those  forms  of  sclerosis  found  in  chronic  myelitis  are  similar  to 
the  connective-tissue  scars  following  destructive  inflammation  else- 


THE    DEGENERATIVE    DISEASES    OF    THE    SPIXAL    COED.         273 

where.  A  person  who  has  a  chronic  myelitis  has  a  cicatrix  in  his 
spinal  cord.  The  sclerosis  of  multiple  sclerosis  is  probably  inflam- 
matory also,  but  it  is  a  neuroglia  rather  than  a  connective-tissue 
cicatrix. 

The  diagrams  in  Fig.  122  show  the  principal  secondary  de- 
generations. Thus  a  iesion  at  the  level  of  the  sixth  cervical  seg- 
ment shows  a  descending  degeneration  in  the  pyramidal  tracts  and 
the  comma-shaped  tract  of  Schultze  below.  A  lesion  at  the  sixth 
dorsal  segment  shows  ascending  degeneration  in  the  column  of  Goll, 


Fig.  133.— Showing  on  the  Right  Side  the  Minor  and  Short  Tracts  Degenerating 
after  Section  of  the  Cord.  A.  ascending  sulco-marginal;  B,  intermediate  lateral  (de- 
scending); C,  comma  tract  (descending) ;  D,  posterior  sulco-marginal ;  L,  Lissauer's. 
Those  tracts  lined  across  degenerate  downward,  the  others  upward. 

direct  cerebellar  tracts,  and  antero-lateral  ascending  tracts  above, 
and  in  the  pyramidal  tracts  below. 

Short  Degenerating  Tracts. — By  the  use  of  more  delicate  stains 
other  degenerating  tracts  have  been  discovered. 

In  the  lateral  column,  scattered  fibres  exist  which  degenerate 
downward.  This  is  the  "  intermediate  tract  of  the  lateral  column" 
(Fig.  12.'),  11 ).  Others  of  the  same  kind  are  found  in  the  anterior 
column.  This  is  the  "sulco-marginal  tract"  (Fig.  12o,  A).  The 
descending  fibres,  some  of  which  degenerate  downward,  some  up- 
ward, come  in  part  from  the  cerebellum,  forming  a  descending  cere- 
bellar tract.  In  part  they  are  long  commissural  fibres  connecting, 
upper  and  lower  spinal  segments. 

In  the  posterior  column  are  two  small  tracts  called  the  "comma 
tracts,"  because  of  their  shape.  They  lie  at  the  junction  of  the 
columns  of  Goll  and  Burdach  in  the  position  shown  in  Fig.  12.".,  ( '. 
The  fibres  degenerate  downward  in  transverse  lesions  of  the  cer- 
vical and  dorsal  cords.  Usually  this  does  not  extend  more  than  an 
inch.  The  tract  may  escape  degeneration  in  locomotor  ataxia 
18 


274  DISEASES    OF   THE   NERVOUS   SYSTEM. 

There  is  a  descending  tract  also  in  the  lumbo-sacral  region  of 
the  cord,  corresponding  in  a  measure  to  the  oval  zone  of  Flechsig. 
As  described  by  Bruce,  it  lies  along  the  posterior  median  septum 
above,  while  below  it  spreads  out  along  the  posterior  margin. 
Bruce  has  called  it  the  posterior  septo-marginal  tract  (Fig.  125,  D). 

LOCOMOTOR  ATAXIA    (Posterior  Spinal  Sclerosis,  Tabes 

DORSALIS)  . 

Definition. — Locomotor  ataxia  is  a  chronic  progressive  disease, 
involving  primarily  the  posterior  spinal  ganglia  or  analogous  neu- 
rons, and  later  the  spinal  cord  and  peripheral  nerves.  It  is  charac- 
terized clinically  by  inco-ordination,  pains,  anaesthesia,  and  various 
visceral,  trophic,  and  other  symptoms,  and  anatomically  by  a  degen- 
erative sclerosis  chiefly  marked  in  the  posterior  columns  of  the  cord 
and  posterior  roots,  and  to  a  less  extent  in  the  peripheral  nerves. 

Forms. — Besides  the  common  and  typical  form,  there  are  anom- 
alous and  complicated  types. 

f  1.  Common  form. 

2.  Neuralgic. 

TyPes-        i   3.  Paralytic. 

4.  "With  initial  optic  atrophy. 

/-.        i-     x.   t    t  With  muscular  atrophy. 

Complicated    \  TT7.,,     ,,  ,  J 

„l  '  W ith  other  scleroses. 

(  "With  general  paralysis. 

Etiology. — The  disease  occurs  oftenest  in  middle  life,  between 
thirty  and  forty,  next  between  forty  and  fifty.  It  may  occur  as 
early  as  the  tenth  and  as  late  as  the  sixtieth  year.  In  the  very 
early  cases  it  is  usually  due  to  hereditary  syphilis.  It  is  much 
more  common  in  males.  Hereditary  influence  is  very  unimportant 
and  is  only  indirect,  i.e.,  the  parents  may  be  neurotic.  Diathetic 
influence  is  slight.  Exposures  to  wet  and  cold,  combined  with 
muscular  exertions,  are  effective  causes.  Soldiers,  travellers,  and 
drivers  are  rather  more  susceptible.  Excessive  railroad  travelling, 
excessive  dancing  with  exposure,  favor  the  development  of  the  dis- 
ease. Excessive  sexual  intercourse,  combined  with  irregular  living, 
is  a  predisposing  cause.  Syphilis  is  by  far  the  most  important 
single  factor.  A  history  of  the  disease  is  obtained  in  from  sixty 
per  cent  to  ninety  per  cent  of  the  cases.  In  my  own  cases  sixty- 
five  per  cent  had  had  syphilis.  The  patient  has  usually  contracted 
the  venereal  disease  ten  or  fifteen  years  before,  and  has  rarely  had 
noticeable  secondary  symptoms.*     Syphilis  is  not  a  direct  factor, 

*  The  following  statistics  from  my  own  experience  show  the  physiognomy 
of  the  disease  in  a  cosmopolitan  American  city.     Total  cases,  190 ;  males,  173 ; 


THE    DEGENERATIVE    DISEASES   OF   THE   SPINAL  CORD.        275 

but  prepares  the  system  for  the  degenerative  process.  Syphilis 
followed  later  by  excesses — mental  or  physical — and  by  exposures 
especially  tends  to  produce  locomotor  ataxia.  Lack  of  proper  treat- 
ment for  syphilis  is  believed  to  favor  the  development  of  the  disease, 
but  a  careful  study  of  the  statistics  of  my  clinic  and  of  his  own 
cases  by  Dr.  Joseph  Collins  seems  to  show  that  antisyphilitic  treat- 
ment as  at  present  carried  out  does  not  prevent  the  disease  if  the 
other  favoring  conditions,  such  as  exhausting  work  and  sexual  or 
alcoholic  excesses,  are  present. 

Among  other  causes  are  profoundly  depressing  emotions,  acute 
infective  diseases  like  typhus,  pneumonia,  and  rheumatism,  difficult 
labors  with  severe  hemorrhage,  prolonged  lactation,  injuries  with 
shock,  and  excessive  smoking. 

Locomotor  ataxia  in  a  somewhat  atypical  form  may  result 
secondarily  from  gummatous  inflammation  of  the  spinal  meninges, 
from  a  tumor,  and  possibly  from  an  ascending  neuritis. 

Symptoms. — The  disease  is  generally  divided  into  three  stages: 
the  initial  or  pre-ataxic,  the  ataxic,  and  the  paralytic. 

1.  The  initial  stage.  The  patient  first  notices  a  slight  uncer- 
tainty in  walking,  especially  at  night;  he  has  numb  feelings  in  his 
feet,  and  at  times  darting  pains  in  the  legs  or  rectum.  His  sexual 
function  becomes  weak,  his  control  over  the  bladder  slightly  im- 
paired. He  has  temporary  attacks  of  vertigo  and  of  double  vision. 
A  continuous  sense  of  profound  weariness  oppresses  him,  even 
though  he  has  made  no  exertion.  The  knee  jerk  is  lost.  Such 
symptoms  may  last  a  few  months  or  several  years. 

2.  The  ataxic  stage.  The  gait  now  becomes  so  unsteady  that 
others  notice  it;  the  patient  has  to  use  a  cane,  and  when  walking 
watch  his  feet  and  the  ground.  If  he  stands  with  his  eyes  closed, 
he  totters  and  may  fail.     His  feet  feel  as  though  there  was  a  layer 

females,  17.  Ages  when  disease  began:  Twenty -one  to  thirty,  19;  thirty- 
one  to  forty,  84;  forty -one  to  fifty.  60;  fifty -one  to  sixty,  22;  sixty -one  to 
seventy,  5.  Average  age  at  time  of  onset,  40;  beginning  a  year  or  two 
earlier  in  private  patients,  and  in  those  with  a  history  of  syphilis  and  active 
antisyphilitic  treatment  (Collins).  Percentage  of  syphilis,  60.  This  is  mak- 
ing the  most  liberal  allowances.  In  one  set  of  eighteen  hospital  patients, 
all  carefully  investigated,  the  percentage  was  70.  Average  period  between 
infection  and  tabes,  fifteen  years,  ranging  from  one  and  one-half  to  twenty- 
five  years.  This  is  much  longer  than  Erb's  estimate,  but  is  reached  by 
three  independent  studies  of  my  cases.  Average  duration  of  disease  when 
seen  by  me,  eight  years ;  average  duration  of  life  in  five  fatal  cases,  twelve 
years,  ranging  from  five  to  twenty  years.  Complications:  optic  atrophy, 
6  per  cent;  marked  arthropathies,  5  per  cent;  with  general  paresis,  4  per 
cent;  paraplegia,  1  5  per  cent;  hemiplegia,  1.6  per  cent;  eye  palsies,  8  per 
cent. 


27G 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


of  cloth  or  cotton  between  the  soles  and  the  ground.  Paroxysms  of 
lightning-like  pains  attack  the  legs,  and  tests  show  anaesthesia  pres- 
ent in  the  toes  and  feet  or  in  patches  on  the  legs.  A  sense  of  con- 
striction is  felt  around  the  waist.  The  sexual  power  is  often  lost; 
the  bladder  is  weak,  and  care  has  to  be  taken  to  empty  it.  The 
bowels  are  constipated;  at  times  he  has  attacks  of  intense  pain  in 
the  epigastrium,  with  vomiting  and  perhaps  a  diarrhoea  coming  on 
without  cause.  The  pupils  are  small  and  do  not  react  to  light  but 
do  react  to  accommodation ;  vision  is  still  good.  The  inco-ordina- 
tion  and  pain  and  anaesthesia  after  a  time  begin  to  affect  slightly 
the  arms.     This  stage  lasts  several  years. 

3.  The  paralytic  stage.  After  several  years  with  various  remis- 
sions and  improvements,  the  patient  loses  altogether  the  power 
of  walking.  His  legs  are  somewhat  wasted,  but  the  muscular 
strength  is  fairly  good.  The  anaesthesia  and  ataxia  are  very  great. 
The  patient  does  not  feel  the  prick  of  a  pin  or  touch  of  the  hand; 
nor  with  closed  eyes  does  he  know  where  his  legs  are.  His  bladder 
is  anaesthetic  and  paretic,  so  that  the  urine  has  to  be  drawn.  The 
pains  are  much  less,  but  are  still  present  at  times.  The  arms  are 
more  involved,  but  never  so  seriously  as  to  make  them  useless  like 
the  legs.  The  intelligence  remains  good,  and  the  patient  may  con- 
tinue bedridden  for  years,  dying  finally  from  some  intercurrent 
affection. 

The  following  table  shows  the  prominent  symptoms  in  the  usual 
order  of  their  appearance : 


First  Stage. 
(Half  to  twenty  years.) 

Second  Stage. 
(Two  to  ten  years.) 

Third  Stage. 
(Two  to  ten  years.) 

Eye  palsies. 

Ataxia. 

Muscular  weakness. 

Less. 

Increased. 

Paresis. 

Increased. 
Paraplegia. 

i 

•  1 

Pains. 

Pains. 
Anaesthesia. 

Pain  less. 
Increased. 

Excito-reflex  . 

•1 

Loss  of  knee  jerk. 
A. -R.  pupil. 

Trophic 

Arthropathies. 

More  rare. 

Rare. 

Sexual  weakness. 
Vesical  weakness. 
Constipation. 

[-  Increased. 

Increased. 

Special  senses. 

r 

\ 

1 
t 

Diplopia. 
Optic  atrophy. 

Rare. 
Rare. 
Deafness. 

Increased. 
Increased. 

Paralysis  of  accom- 

modation. 

THE   DEGENERATIVE    DISEASES   OF   THE    SPINAL   CORD.        277 


The  symptoms  must  now  be  analyzed  more  closely. 

Locomotor  and  static  ataxia  are  present  very  early,  but  only  to  a 
moderate  extent.  Tests,  such,  as  making  the  patient  walk  and  stand 
with  the  eyes  closed,  noting  the  position  of  limbs  and  the  weight  of 
objects,  will  reveal  an  ataxia  due  largely  to  beginning  ansesthesia  of 
the  joints  and  tendons.  By  the  use  of  the  ataxigraph,  one  can  with 
care  assure  himself  that  the  patient  has  an  excessive  degree  of  static 
ataxia.  In  my  experience,  when  the  ataxigraph  records  over  three 
inches'  oscillation,  the  patient  not 
being  paraplegic  or  under  the  in- 
fluence of  any  drag,  it  is  abnormal. 

The  patella-tendon  reflex  or  knee 
jerk  is  abolished  very  early  in  all 
typical  cases.  This  constitutes  a 
very  important  symptom,  therefore. 

The  (jo  it  and  station  in  ataxia  are 
characteristic.  In  walking,  the  pa- 
tient keeps  his  eyes  on  the  ground 
and  on  his  feet.  The  latter  he 
throws  out  rather  forcibly,  owing  to 
overaction  of  the  extensors  of  the 
foot.  In  watching  such  a  patient 
walk  barefooted,  the  extensor  ten- 
dons can  be  seen  to  stand  out  with 
each  forward  movement  of  the  iimb. 
The  foot  is  brought  down  sharply  on 
the  heel  and  the  legs  are  spread  apart 
a  little.  Turning  a  corner,  turning 
around,  and  going  downstairs  are 
done  awkwardly,  and  the  patient  is 
apt  to  totter  and  fall.  Walking  on 
a  chalked  line  is  very  difficult;  so 
also  is  walking  backward.  The  gait  improves  after  the  patient 
walks  a  while,  and  he  will  generally  say  that  the  practice  of  walking 
does  him  good.     Still,  he  soon  gets  tired  (Fig.  124). 

Severe  rectal  neuralgia,  associated  perhaps  with  hemorrhoids,  is 
sometimes  an  early  symptom.  Persistent  neuralgia  and  functional 
disturbance  of  the  bladder  and  rectum  should  cause  suspicion  of 
ataxia.  Lancinating  or  lightning  pains  occur  and  are  very  charac- 
teristic. The  pains  dart  down  the  legs  along  the  course  of  the 
sciatic,  or  they  suddenly  appear  as  patches  of  pain  on  the  foot  or  leg 
or  thigh  ("spot  pains").  The  pain  comes  unexpectedly  and  with 
such  severity  that  the  patient  involuntarily  jumps  or  jerks  the  limb. 


Fig.  134.— Showing  Station  in  Second 
Stage  op  Locomotou  Ataxia. 


278 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


He  speaks  of  his  "  jerking"  and  "  twitching  pains. "  The  pains  may 
affect  the  bowels  or  be  felt  as  a  squeezing  sensation  around  the 
waist  (girdle  pains).  The  pains  of  ataxia  are  often  the  most  obsti- 
nate and  distressing  symptom.  They  usually  come  on  in  great  in- 
tensity once  or  twice  a  month,  and  last  for  two  or  three  days.  They 
then  leave  the  patient  for  a  time.  They  are  often  worse  in  cold  and 
damp  weather.     In  some  cases  the  pains  are  almost  continuous, 


135 
140 


ra  m 


Fie.  125.  —  Irregularly  Contracted  Visual  Field  in  Case  of  Tabes  with  Optic 
Atrophy,  Left  Eye  (Berger). 


coming  on,  if  not  every  day,  at  least  two  or  three  times  a  week. 
Such  cases  are  associated  with  much  cutaneous  hyperesthesia,  espe- 
cially during  the  attacks.  This  type  of  cases  is  called  "  the  neural- 
gic." The  patients  rarely  have  as  much  ataxia,  paresis,  or  visceral 
troubles  as  the  typical  forms  present,  and  in  certain  respects  such 
cases  are  favorable. 

The  pains  of  the  disease  continue  well  into  the  second  and  even 
third  stage.  Meanwhile  the  anaesthesia  becomes  much  more  marked. 
It  affects  most  the  feet  and  next  the  legs,  rarely  extending  much 
over  the  thighs,  but  passing  to  the  fingers  and  hands.     The  anses- 


THE    DEGENERATIVE    DISEASES    OF   THE    SPINAL   CORD.        279 

thesia  is  greatest  to  pain,  but  touch  and  temperature  sense  are  also 
involved.  There  is  often  delayed  conduction  and  polyaesthesia; 
many  other  curious  perversions  of  the  cutaneous  sense  are  noted. 
Some  anaesthesia  usually  develops  over  the  finger  tips  and  hands, 
and  sometimes  a  band  of  anaesthesia  develops  about  the  trunk. 
The  facial  and  cranial  nerves  are  not  much  affected,  but  there  may 
be  trigeminal  neuralgia. 

Optic  atrophy  occurs  in  about  six  per  cent  of  cases,  in  my 
experience.  Optic  atrophy  usually  develops  in  the  pre-ataxic  stage. 
If  a  patient  has  reached  the  second  stage  without  it,  he  will  prob- 
ably escape  it  altogether.  Cases  with  ocular  paralyses  are  slightly 
more  disposed  to  it  (Berger).  It  attacks  the  left  eye  oftenerthan 
the  right.  The  atrophy  begins  sometimes  with  increased  sensi- 
bility to  light,  flashes  of  light,  and  muscae  volitantes.  With  the 
failing  vision,  disturbance  of  color  sense  often  and  contraction  of 
the  visual  field  always  occur.  This  contraction  is  irregular,  with 
sector-formed  defects;  not  hemiopic  (Fig.  125).  The  atrophy  pro-, 
gresses  slowly  with  slight  remissions.  It  may  cease  its  progress, 
but  this  is  rare.  Blindness  comes  in  about  three  years.  Ophthal- 
moscopically  there  may  be  seen  slight  evidence  of  congestion  in 
the  early  stage;  later,  pallor  of  the  disc,  which  finally  becomes 
grayish. 

Disorders  of  hearing  are  frequent  in  tabes,  occurring  in  about 
one-fourth  of  the  cases,  but  in  the  majority  of  instances  the  aural 
trouble  is  an  accidental  complication  due  to  middle-ear  disease. 
Primary  atrophy  of  the  auditory  nerve  is  very  rare,  as  might  be 
expected,  since  this  nerve  is  structurally  not  like  the  optic  nerve. 
Its  existence  has  been  inferred  on  clinical  grounds.  Another  form 
of  tabetic  deafness  is  of  trophic  origin  and  due  to  a  sclerotic  condi- 
tion of  the  middle  ear  (Treitel).  It  is  caused  by  involvement  of 
the  trophic  or  vasomotor  fibres  of  the  fifth  nerve. 

The  senses  of  taste  and  smell  are  rarely  affected. 

The  eye  muscles  are  implicated  in  some  way  in  nearly  all  cases 
of  tabes.     The  following  are  the  disorders : 

1.  Loss  of  the  light  reflex,  and  myosis.  2.  Sympathetic-nerve 
ptosis.  3.  Paralysis  of  branches  of  the  third  nerve.  4.  Paralysis 
of  the  sixth  nerve. 

Paralyses  of  the  ocular  muscles  (third  and  sixth)  occur  rather 
oftener  in  distinctly  syphilitic  cases.  Other  ocular  troubles  are  not 
influenced  by  exudative  syphilis.  Ocular  palsies  are  early  symp- 
toms of  the  disease,  occurring,  as  a  rule,  in  the  pre-ataxic  stage. 

1.  Loss  of  light  reflex  and  pupillary  rigidity.  Tim  pupils  are 
small  and  sometimes  uneven;  they  d.0  not  respond  to  light,  but  they 


280 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


do  to  accommodation.  This  condition  is  known  as  the  Argyll' 
Robertson  pupil.  In  early  stages  the  light  reflex  may  be  simply 
sluggish.  In  the  late  stages  the  accommodation  reflex  is  also  lost. 
The  Argyll-Eobertson  pupil  is  practically  found  only  in  tabes  and 
in  general  paresis.  The  ocular  skin  reflex  usually  disappears  early. 
The  myosis  in  tabes  is  due  to  paralysis  of  the  sympathetic  dilating 
fibres.  The  pupils  are 
sometimes  irregular  in 
shape.  In  some  cases 
there  is  a  loss  of  both 
light  and  accommoda- 
tion reflex.  This  is 
especially  characteris- 
tic of  an  exudative 
bram  syphilis  (Sachs). 
2.  Sympathetic- 
nerve  ptosis.  A  slight 
drooping  of  one  or 
both  iids  is  not  infre- 


Fig.  126.—  Arthropathy 
of  Ankle. 


Fig.  127.— Arthropathy  Involving  Knees 
and  Long  Bones  op  Legs. 


quent.  It  begins  early  and  progresses  slightly  up  to  the  later  stages 
of  the  disease.  It  is  due  to  paralysis  of  the  sympathetic-nerve 
fibres  of  the  lid. 

3,  4.  Paralysis  of  the  external  eye  muscles.  The  external 
rectus  is  oftenest  affected  of  single  muscles,  but  the  various  branches 
of  the  third  nerve  taken  together  are  oftener  involved  than  the  sixth. 
Of  the  third  nerve's  branches,  the  levator  palpebrse  and  internal 
recti  muscles  are  oftenest  involved.  There  maybe  multiple  palsies. 
These  occur  oftener  in  syphilitic  cases.  Progressive  ophthalmo- 
plegia may  be  associated  with  tabes.  The  ocular  nerve  palsies  may 
7oe  transitory  or  permanent.     Those  occurring  in  the  pre-  ataxic  stage 


THE    DEGENERATIVE    DISEASES    OF    THE    SPINAL    COED.        281 

are  usually  transitory,  lasting  a  few  hours,  days,  or  weeks.  Cases 
have  even  lasted  two  years  and  got  well.  The  permanent  palsies 
develop  usually  in  the  later  stages.  The  early  palsies  are  usually 
due  to  a  syphilitic  exudation  at  the  base  of  the  brain ;  the  late  pal- 


Fig.  128.— Arthropathy  op  Knees  in  Tabes,  Showing  Relaxed  Joints. 

sies  are  usually  due  to  degenerative  lesions  of  the  nuclei  of  the 
ocular  nerves. 

The  arthropathies  oflocomotor  ataxia  Degenerative  diseases  of 
the  joints,  technically  known  as  arthropathies,  and  spontaneous 
fractures  of  bones  form  important  symptoms  of  tabes.  They  occur 
in  ten  per  cent  (Charcot  |  <>r  five  per  cent  (author  i  of  ca 

The  arthropathies  are  three  or  four  times  more   frequent  than 


282  DISEASES    OF   THE    NERVOUS    SYSTEM. 

the  fractures.  The  joints  oftenest  affected  are  the  knees,  ankles, 
and  hips;  but  the  elbow,  shoulder,  wrist,  and  small  joints  may  be 
attacked. 

Spontaneous  fractures  occur  oftenest  in  the  shaft  and  neck  of 
the  femur,  next  in  the  legs,  forearm,  humerus,  and  clavicle.  The 
pelvis,  scapula,  vertebras,  and  under  jaw  may  be  fractured.  Arthro- 
pathies are  often  accompanied  by  fractures,  especially  of  the  heads 
of  the  bones.     The  two  sides  of  the  body  are  about  equally  affected. 

The  arthropathies  are  characterized  by  a  sudden,  apparently 
spontaneous  painless  swelling  of  the  joint.  The  symptoms  may  de- 
velop in  twenty-four  or  forty-eight  hours.  In  rare  cases  there  is  a 
history  of  some  preceding  rheumatic  pains  or  of  an  injury.  After  a 
time  there  is  an  osseous  hyperplasia  of  the  joint,  which  becomes 
enlarged  to  enormous  proportions.  There  is  also  a  tendency 
to  luxation  of  the  joint.  It  crepitates  on  moving.  There  is 
no  tenderness  on  pressure ;  the  hand  finds  evidence  of  synovial  exu- 
dation, roughened  surfaces,  and  perhaps  fractures  of  the  enlarged 
parts.  In  the  milder  forms  there  are  simply  swelling  from  synovial 
exudation  and  some  enlargement  of  the  bones  with  roughened  sur- 
faces. After  a  few  weeks  this  swelling  may  subside  and  the  joint 
return  to  nearly  its  natural  size.  In  other  cases  the  process  pro- 
gresses, the  ligaments  relax,  the  bones  of  the  joint  can  be  moved 
about  freely,  and  luxations  are  easily  produced.  There  is  still  no 
pain,  but  the  limb  becomes  almost  or  entirely  useless  on  account 
of  the  loose  and  relaxed  condition  of  the  parts  (Fig.  130).  As 
time  goes  on,  some  absorption  takes  place  and  the  head  of  the  bone 
may  almost  disappear.  The  arthropathies  have  been  divided  into 
benign  and  malignant;  but.  no  sharp  line  can  be  drawn  or  certain 
prognosis  made  in  the  early  stage.  The  arthropathies  appear  in  the 
prodromal  and  early  stage  of  the  disease  in  over  half  the  cases,  and 
are  often  at  first  unrecognized.  One-third  occur  after  the  tenth  year 
of  the  disease. 

The  spontaneous  fractures  are  usually  brought  on  by  a  slight 
trauma,  such  as  a  fall.  Violent  muscular  movements  may  produce 
them.  They  also  are  painless,  as  a  rule.  The  fractures  usually 
heal  well,  often  with  abnormal  readiness,  but  occasionally  there  is 
delay,  and  often  healing  is  accompanied  by  great  throwing  out  of 
callus. 

Pathologically  the  arthropathy  is  a  rarefying  osteitis.  It  does 
not  differ  anatomically  from  arthritis  deformans,  except  that  frac- 
tures may  accompany  it.  Clinically  the  chief  difference  lies  in  the 
abruptness,  spontaneity,  and  painlessness  of  the  process.  The  dis- 
ease, on  the  whole,  cannot  be  considered  specifically  different  from 
arthritis  deformans,  modified  by  the  analgesia  of  the  parts.     It  is 


THE    DEGENERATIVE    DISEASES    OF   THE    SPINAL    CORD.        283 


due  probably  to  a  degenerative  change  in  the  nerves  supplying  the 
joints  and  bones.  The  process  may  begin  in  the  cartilage,  bone,  or 
ligaments.  Eventually  all  these  parts  are  involved.  There  is  con- 
gestion of  the  synovial  membranes  with  hydrarthrosis,  then  atrophy 
and  rarefying  hypertrophy  of  the  epiphyses,  relaxation  of  the  liga- 
ments, formation  of  osteophytes  and  bony  stalactites.  There  may 
be  a  rarefying  osteitis  of  the  long  bones,  without  much  joint  involve- 
ment at  first  (Fig.  127). 

Various  trophic  disturbances  of  the  skin  may  appear,  generally 
late  in  the  disease.     The  most  common  are  herpes  and  lichen.     Be- 
sides   these,    bullae,    transitory    ery- 
^       ^  thema,  urticaria,  eczema,  pemphigus, 

ecthyma,  ulcers,  ichthoysis,  and  pete- 
chiae  have  been  described;  but  they 
are  rare  and  often  only  accidental 
complications.  A  peculiar  round  per- 
forating ulcer  sometimes  develops  on 
the  sole  of  the  foot,  often  as  the  re- 
sult of  cutting  a  corn.  In  rare  cases 
the  nails  and  teeth  fall  out.  In  dis- 
tinctly syphilitic  cases  there  is  usually 
baldness. 

Peculiar  "crises "of  various  kinds 
occur  in  tabes.  The  most  common 
are  gastric  crises.  These  consist  of  at- 
tacks of  intense  pain  extending  from 
the  groin  to  the  epigastrium  or  en- 
circling the  waist,  accompanied  by 
vomiting  and  sometimes  diarrhoea. 
The  attacks  are  often  associated  with 
pains  in  the  legs.  They  last  two 
or  three  days,  then  pass  away. 

Laryngeal  crises  consist  of  attacks  of  spasm  of  the  adductors  or 
paralysis  of  abductors,  with  noisy,  croupy  respiration.  The  attacks 
come  on  suddenly,  the  patient  coughs  and  struggles  for  breath,  and 
he  may  be  seized  with  vertigo  and  fall  down.  The  pulse  may  be 
very  fast.  The  paroxysm  lasts  for  a  few  minutes  to  several  hours. 
The  symptoms  are  very  distressing,  but  not  dangerous.  Paroxysms 
of  cough  have  been  described  as  "bronchial  crises."  There  are  also 
cardiac  crises,  in  which  there  are  dyspnoea  and  rapid  heart  beat  and 
sense  of  suffocation  resembling  angina.  The  heart  itself  sometimes 
is  diseased,  but  whether  from  neurotrophic  disturbance  or  not  is 
doubtful.  The  pulse  is  often  small,  rather  rapid,  and  weak.  The 
laryngeal  and  heart  crises  both  depend  on  a  degenerative  disease 


Fig.   129.— Perforating    Ulcer 
Foot  in  Tabes. 


284  DISEASES    OF   THE   NERVOUS    SYSTEM. 

and  irritation  of  the  vagus,  and  may  be  more  or  less  united  in  symp- 
toms. 

A  sense  of  great  weariness  and  heaviness  in  the  limbs,  present 
constantly,  no  matter  how  much  rest  is  taken,  is  a  characteristic 
early  symptom,  and  is  due  to  an  irritability  of  the  nerves  of 
muscular  sensibility. 

Muscular  atrophias  occur  sometimes  in  tabes.  They  are  of  three 
kinds:  1st,  a  true  progressive  muscular  atrophy  due  to  degeneration 
of  trophic  and  motor  cells ;  2d,  localized  muscular  atrophies  due  to 
degenerative  atrophy  of  nerves;  3d,  a  general  wasting.  Under  the 
first  head  one  finds  ophthalmoplegia,  bulbar  paralysis,  and  spinal 
amyotrophy:  Under  the  second,  wasting  of  certain  groups  of 
muscles  in  the  legs  or  arms. 

Besides  these,  there  is  a  generalized  atrophy  which  occurs  in  the 
paralytic  stage  and  is  due  probably  to  a  slight  involvement  of  the 
anterior  horns  in  the  progressive  process  that  affects  the  cord. 

Attacks  of  hemiplegia  in  rare  instances  occur  in  tabes.  They 
are  usually  of  temporary  character  and  occur  early  in  the  disease. 
They  may  come  on  late  and  are  then  more  likely  due  to  acute  soft- 
ening. In  all  cases  the  trouble  is  due  to  embolism  or  to  disease  of 
the  cerebral  vessels,  of  syphilitic  origin. 

Acute  paraplegia  comes  on  occasionally  also,  and  this  sometimes 
almost  disappears. 

The  sexual  power  may  be  at  first  greatly  exaggerated;  but  this 
is  rare,  and  usually  there  is  progressive  weakness  and  loss  of  desire. 
The  bladder  and  sexual  functions  are  rarely  entirely  lost  and  rarely 
equally  impaired  in  the  first  stage;  one  may  continue  good  while 
the  other  is  affected  moderately.  Usually  the  sexual  function  goes 
first. 

Some  oerebral  symptoms  occur  in  tabes,  chiefly  in  the  early  stage. 
They  are  insomnia,  which  may  be  very  obstinate;  and  occasional 
vertigo.  An  irritability  of  temper  and  tendency  to  despondency, 
sometimes  noted,  cannot  be  considered  unnatural.  Apoplectiform 
and  epileptiform  attacks  are  described,  but  are  very  rare,  and  should 
cause  a  suspicion  of  a  complication.  The  disease  in  very  rare  cases 
terminates  in  general  paresis. 

Course. — The  disease  has  been  termed  progressive,  but  it  is  not 
so  in  a  large  number  of  cases.  With  proper  treatment  the  symp- 
toms can  often  be  kept  in  control  for  years.  The  first  stage  may 
last  twenty  years  or  more;  the  second  stage  five  to  fifteen  years. 
The  total  duration  of  the  disease  varies  enormously,  ranging  between 
three  and  thirty  years.  A  few  acute  cases  have  been  observed, 
running  a  course  of  less  than  a  year. 

Complications. — These  are  acute  myelitis,  generally  syphilitic; 


THE    DEGENERATIVE    DISEASES   OF   THE    SPINAL    CORD.         285 

lateral   sclerosis,   progressive   muscular  atrophy,    hemiplegia  from 
embolism  or  endarteritis,  general  paresis,  and  heart  disease. 

Pathological  Anatomy  and  Pathology.  —  The  characteristic 
changes  are  found  in  the  spinal  cord,  posterior  spinal  ganglia  and 
posterior  roots,  and  to  a  less  extent  in  the  peripheral  nerves.  The 
spinal  cord  usually  is  reduced  in  size  and  flattened  antero- 
posteriorly;  the  pia  mater  is  thickened  somewhat.  One  can  see 
with  the  naked  eye  that  the  posterior  columns  of  the  cord  are 
shrunken  and  have  a  grayish  appearance. 


Fro.  1:30.  Fio.  I8L 

Fia.  130.— Locomotor  Ataxia,  showing  areas  affected  in  first  stage  at  five  different 

levels.    Drawn  from  specimens  in  author's  possession  and  from  comparative  study  of 

twer  thirty  other  figures. 

Fio.  131.— Locomotor  Ataxia,  Second  Stage. 


286 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


Under  the  microscope  it  can  be  seen  that  the  white  matter  of 
the  posterior  columns  is  very  seriously  affected ;  the  nerve  tisue  has 
disappeared,  and  its  place  is  taken  by  connective  and  neuroglia  tissue 
through  which  a  few  nerve  fibres  still  run.  The  walls  of  the  blood- 
vessels are  somewhat  thickened, 
but  not  remarkably  so,  nor  is  there 
any  notable  evidence  of  congestion 
or  excessive  vascular  irritation. 

The  part  of  the  posterior  column 
first  affected  is  a  vertical  streak 
lying  in  the  middle  root  zone  be- 
tween the  posterior  median  (col- 
umns of  Golf)  and  posterior  external 
columns  (columns  of  Burdach)  (Fig. 
130).  The  segments  first  and  most 
affected  are  those  of  the  upper 
lumbar  and  lower  dorsal  region. 
Besides  this  area  the  rim  zone  or 
column  of  Lissauer  is  also  early 
involved.  As  the  disease  pro- 
gresses it  extends  upward  and 
spreads  laterally  so  that  finally  all 
of  the  posterior  column  is  changed 
into  a  dense  connective-tissue  mass 
through  which  only  a  few  nerve 
fibres  run.  The  part  last  and  least 
involved  is  that  lying  just  posterior 
to  the  commissure  (anterior  root 
zone  of  Flechsig,  ventral  funda- 
mental column)  and  that  lying  just 
mesial  of  the  posterior  horns  (ex- 
ternal part  of  the  middle  root  zone) 
(Fig.  132).  There  is  sometimes 
a  degeneration  of  the  antero- 
lateral ascending  tract  (Gowers' 
tract),  and  very  rarely  of  the 
cerebellar  tract.  The  pyramidal 
tracts  are  involved  only  in  com- 
plicated cases.  The  cells  and 
fibres  of  the  column  of  Clark  are 
often   involved  in  advanced    cases 

(Fig.  133).      The  gray  matter   of 
Fig.  133.-LocOgMOTOR  Ataxia,  Last        ^    ^    pogterior     and      anterk)r 


THE    DEGENERATIVE    DISEASES   OF   THE   SPINAL   CORD. 


287 


horns  may  show  some  degenerative  changes,   viz.,   decrease  of  the 
fibre  network  and  atrophy  of  the  cellular  elements. 

The  posterior  roots  are  usually  involved,  the  process  extending 
as  far  as  the  spinal  ganglia,  which  also  show  some  degeneration 
(Figs.  134,  135),  but  the  lesion  is  not  strikingly  marked  here  in  all 
cases,  and  sometimes  the 
spinal  ganglia  are  nearly 
healthy,  although  the 
posterior  columns  are 
diseased.  The  anterior 
roots  are  normal. 

The  process  begins 
in  the  upper  lumbar 
cord ;  the  sacral  cord  is  usually 
much  less  affected.  However, 
the  exact  initial  point  of  at- 
tack varies,  and  this  accounts 
for  the  variation  in  the  symp- 
toms. Cases  that  begin  with 
decided  bladder  and  genital 
symptoms  probably  start  low 
down;  cases  which  go  for  a 
good  while  with  only  ataxia, 
loss  of  knee  jerk,  and  pains 
begin  higher;  while  in  the 
brachial  or  arm-type  cases  the 
process  begins  in  the  cervical 
enlargement. 

The  peripheral  nerves  are 
diseased  in  a  large  number  of 
the  advanced  cases.  T  h  e 
nerves  of  the  leg  are  most  in- 
volved. The  process  is  a  de- 
generative atrophy  or  neuritis 
(Figs.  136,  137).  It  affects  the 
extremities  of  the  nerves  first 
and  slowly  extends  upward, 
seldom  reaching  the  large 
trunks. 

Sometimes  the  disease  be- 

,  Fig.  133.— Showing  Columns   of  Clark.    1, 

gll'.S    in    the     Optic      nerves    Or  Normal;  a,  diseased,  in  case  of  tabes  in  third 

possibly  in    the     bipolar    visual  st"ge;   with  degeneration  of  posterior  columns 

_   n          £      j_t_             ,  •                 <™  •  an(l  cerebellar  tracts  as  shown  in  3  (Oppen- 

cells    of     the    retina.        This  heim1. 


288 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


should  be  the  case  in  order  to  observe  the  neuronic  homologies.  The 
process  here  is  an  atrophy  beginning  at  the  periphery  and  extending 
brainward.  The  third,  fifth,  and  sixth  nerves  are  occasionally  in- 
volved; still  more  rarely  the  olfactory  and  auditory.  The  vagus 
nerve  and  sometimes  its  nucleus  and  that  of  the  glosso-pharyngeal 
are  implicated,  it  may  be,  rather  early  in  the  disease.  It  is  believed 
that,  these  facts  explain  many  of  the  laryngeal  and  visceral  crises. 


JfiM 


3m 


Gangt- 


ZlerV. 


Fig.  134.  Fig.  LJ5. 

Fig.  134. — Posterior    Spinal  Ganglion  in  Third  Stage  of  Tabes. 
root;  A.R.,  anterior  root  (Oppenheim). 
Fig.  135. —  Healthy  Spinal  Ganglion. 


~-A.R> 


P.R.,  posterior 


Pathology. — The  pathology  of  locomotor  ataxia  cannot  be  thor- 
oughly understood  without  a  knowledge  of  the  pathology  of  syphilis 
in  its  relation  to  the  nervous  system — a  subject  which  is  discussed 
later.  It  may  be  said  here,  however,  that  syphilis  leads  to  two  sets 
of  changes  in  the  nervous  system:  one,  the  earlier,  is  inflammatory; 
the  other,  and  later,  is  degenerative.  The  inflammatory  changes 
attack  the  blood-vessels  and  serous  membranes,  leading  to  the  deposit 
of  exudates,  and  these  are  the  characteristics  of  secondary  syphi- 
lis when  it  involves  the  nerve  centres.  The  degenerative  changes 
attack  the  nerve  tissue  directly.     They  follow  long  after  the  infec- 


THE    DEGENERATIVE    DISEASES    OF   THE    SPINAL    CORD. 


289 


tion  and  are  the  result  of  the.  syphilitic  poison  which  has  been  per- 
meating the  system.  Degenerative  syphilis  of  the  nervous  system 
is  not,  strictly  speaking,  syphilis  at  all,  but  rather  the  effects  of 


Fig.  136.— Plantar  Nerve,  Simple  Atrophy  in  Tabes. 

it,  just  as  the  parched  and  dying  turf  is  the  result  of  the  fire  which 
has  swept  over  it.  Neurology  knows  no  tertiary  syphilis,  but  the 
disease  departs,  leaving  a  trail  behind  it  which  sets  in  motion  the 
processes  of  decay  and  death  of  the  parts.  This  is  what  happens  in 
locomotor  ataxia,  which  is  the  Parthian  shot  of  thf  conquered  infec- 


Fio.  137.— Ulnar  Nerve,  Tbjkd  Stase  Tabes,  Atrophy  with  Proliferation  of  Connec- 
tive Tissue  (Oppenheim). 

tion.  Syphilis  often  invades  the  nerve  centres  and  frankly  shows 
itself  in  the  form  of  inflammatory  and  gummatous  exudates,  but 
often  it  does  not  betray  its  presence  and  does  its  final  work  quietly 
through  years  of  apparent  health.     All  the  time,  however,  its  poison 

"  l'.t 


290  DISEASES    OF    THE   NERVOUS    SYSTEM. 

is  at  work  instituting  a  tendency  to  death  and  degeneration  in 
certain  parts  of  the  nerve  centres.  The  parts  which  are  usually 
first  selected  are  the  posterior  spinal  ganglia,  and,  particularly,  the 
neuraxons  which  pass  from  the  nerve  cells  of  these  ganglia  into  the 
posterior  roots  and  columns  of  the  spinal  cord.  Locomotor  ataxia, 
therefore,  is  not  primarily  a  sclerosis  of  the  posterior  spinal  columns, 
but  of  the  peripheral  sensory  neurons.  It  is  true  that  the  posterior 
spinal  ganglia  are  not  always  so  seriously  diseased  as  the  posterior 
columns  of  the  cord.  This,  however,  is  because  the  severity  of  the 
disease  is  first  shown  in  the  neuraxons  and  their  collaterals,  just  as 
in  alcoholic  neuritis  the  peripheral  parts  of  the  motor  neuraxons 
are  most  and  earliest  affected  by  alcohol.  As  the  disease  extends,  it 
involves  both  the  peripheral  and  central  parts  of  these  sensory 
neurons;  that  is  to  say,  both  the  sensory  fibres  and  the  posterior 
spinal  roots.  Still  later  it  attacks  other  portions  of  the  nerve 
centres,  so  that  in  the  last  stages  much  of  the  nervous  sys- 
tem is  diseased.  The  reason  why  the  peripheral  sensory  neu- 
rons are  especially  affected  rather  than  other  parts  seems  to 
me  to  be  this:  the  syphilitic  poison  is  brought  to  the  nerve 
centres  in  the  blood,  whence  it  passes  into  the  lymphatic 
sheaths  of  the  blood-vessels  or  is  thrown  out  upon  the  serous  mem- 
branes in  the  subdural  sacs.  In  the  attempts  of  nature  to  get  it  out 
of  the  spinal  canal  and  eliminate  it,  the  poison  is  carried  along  the 
serous  sheaths  which  surround  the  cerebro-spinal  nerve  roots.  The 
nerves,  as  they  pass  out  from  the  spinal  cord,  are  covered  with  three 
membranes:  the  dura  mater,  the  arachnoid,  and  the  pia  mater. 
The  dura  and  the  arachnoid  surround  them  less  tightly  than  the 
other.  The  dura  becomes  fused  with  the  connective  tissue  support- 
ing the  nerves  as  they  pass  out,  and  the  arachnoid  becomes  fused 
with  the  epineurium  and  perineurium.  Now,  fluid  injected  into 
either  the  subdural  or  subarachnoid  spaces  passes  readily  along 
the  nerves  for  some  distance  (Macewen),  and  syphilitic  exudate 
in  the  subarachnoid  and  subdural  spaces  of  the  spinal  cord  will 
thus  have  a  tendency  to  infiltrate  along  these  sheaths,  but  as  it 
passes  out  of  the  vertebral  canal  or  cranial  cavity  it  meets  mechani- 
cal obstacles,  owing  to  the  constriction  of  the  parts,  and  there  is 
therefore  a  certain  damming  up  or  accumulation  of  the  poisonous 
material  at  these  points  of  exit.  Generally  at  this  point  it  meets 
with  the  posterior  spinal  ganglia,  a  highly  organized  structure  with 
special  vascular  supply,  and  it  therefore  naturally  deposits  its  poison 
upon  this  part,  which  furnishes  much  more  opportunity  for  mischief 
than  the  non-vascular  anterior  roots.  It  is  a  fact  that  many  of  the 
initial  symptoms  of  locomotor  ataxia  are  thus  connected  with  such 


THE    DEGENERATIVE    DISEASES    OF   THE-  SPINAL   CORD.        291 

troubles  as  would  occur  from  an  exudate  trying  to  get  out  along  the 
course  of  the  spinal  or  cranial  nerves.  A  frequent  initial  symp- 
tom, for  example,  is  palsy  of  one  of  the  third  nerves  or  of  the  sixth 
or  seventh  nerves,  due  to  exudates  clinging  around  their  roots.  Still 
more  frequently  the  initial  symptom  is  a  neuralgic  pain  in  the 
course  of  the  sciatic  plexus,  due  to  the  effects  of  this  poison  upon  the 
ganglia  lying  in  the  lumbar  intervertebral  spaces. 

I  assume  in  this  description  that  it  is  a  syphilitic  poison  which 
is  always  at  work  as  a  cause  of  tabes  dorsalis.  This,  however,  is 
not  necessarily  the  case,  for  it  may  be  the  infection  of  other  diseases, 
and  the  results  of  other  poisons,  such  as  ergot,  pellagra,  lead,  etc., 
are  to  be  explained  in  the  same  way.  There  is  an  inadequacy  of  the 
lymphatic  and  venous  systems  to  thoroughly  rid  the  spinal  canal  of 
the  poisons  that  lie  in  it;  the  body  of  the  cord  is  cleared,  but  the 
roots  do  not  get  rid  of  the  poison.  In  a  word,  I  would  say  that 
locomotor  ataxia  is  a  post-infective  degeneration  which  first  attacks 
the  posterior  spinal  ganglia  or  corresponding  cells  of  the  special 
senses,  due  to  a  prolonged  poisoning  of  these  parts  by  the  toxins  of 
the  infection,  whatever  this  may  be. 

As  to  why  this  process  attacks  some  and  not  others,  it  can  only 
be  said  that  certain  people  are  born  with  defective  power  of  resist- 
ance as  regards  their  nerve  centres,  and  that  others  induce  this 
defective  state  by  physical  and  other  excesses.  ■ 

The  diagnosis  is  not  difficult  in  the  advanced  stages.  In  the  first 
stage  the  disease  has  to  be  distinguished  from  hereditary  ataxia, 
multiple  neuritis,  chronic  myelitis^  spinal  tumor,  spinal  syphilis, 
general  paresis,  and  neurasthenia.  In  hereditary  ataxia  the  age, 
the  history  of  the  disease,  and  the  absence  of  lightning  pains  are 
usually  sufficient  to  distinguish  it.  Multiple  neuritis,  in  its  sen- 
sory or  pseudo-tabetic  form,  sometimes  resembles  closely  locomotor 
ataxia.  The  differential  points  are  given  in  the  sections  devoted  to 
that  disease.  In  myelitis  there  is  more  paralysis,  generally  exag- 
geration of  reflexes,  and  an  absence  of  disturbance  of  special  senses. 

The  diagnostic  criteria  of  locomotor  ataxia  in  all  cases  are  the 
presence  of  lightning  pains,  numbness  of  the  feet,  loss  of  knee  jerk, 
ataxia  of  station  and  gait,  without  much  loss  of  muscular  power, 
the  presence  of  the  Argyll-Robertson  pupil,  the  history  of  syphilis, 
and  the  slow  onset  of  the  disease.  A  lost  knee  jerk,  lightning  pains, 
and  stiff  pupils  are  usually  quite  enough  to  assure  a  diagnosis. 

Prognosis.  —  In  the  first  stage  a  small  percentage  may  have  the 
disease  stopped  and  get  practically  well.  After  the  second  stage  a 
cure  is  impossible,  but  great  improvement  may  be  secured  and  the 
patient  made  relatively  comfortable  for  years. 


29:2  DISEASES   OF   THE    NERVOUS   SYSTEM. 

In  the  third  stage  little  can  be  clone  except  to  relieve  the  symp- 
toms, but  life  may  be  prolonged.  Death  usually  occurs  from  some 
intercurrent  malady,  or  from  kidney  disease  caused  by  the  bladder 
trouble.  Patients  very  rarely  indeed  die  from  the  disease  itself  and 
its  various  "crises." 

Treatment. — The  treatment  of  locomotor  ataxia  is  a  subject  the 
discussion  of  which  cannot  be  made  dogmatic,  for  the  treatment  de- 
pends very  largely  upon  the  patient  and  the  stage  and  cause  of  the 
disease.  My  experience  is  that  any  treatment  depends  enormously 
upon  one's  opportunities  of  getting  the  patient  in  the  earliest  stages. 
Supposing  this  be  done,  the  first  thing  is  to  be  quite  assured  that 
there  is  no  trace  of  a  secondary  (or  exudative)  syphilis  underlying 
the  trouble.  If  some  of  the  symptoms  are  caused  by  such  exudate, 
inunctions  of  mercury,  warm  baths,  and  iodide  of  potassium  should 
be  given  vigorously  and  persistently. 

1  have  seen  no  proof  that  inunctions  are  better  than  the  internal 
use  of  mercury,  but  they  are  recommended  by  authorities  eminent 
in  neurology  if  not  in  cutaneous  sensitiveness.  I  usually  pre- 
scribe the  bichloride  in  gr.  -^  doses  and  combine  it  with  tinc- 
ture of  iron.  The  iodide  of  strontium  is  often  a  grateful  change 
from  potash.  It  is  to  be  given  in  daily  doses  of  about  60  grains, 
but  this  may  be  increased  to  600  grains  or  900  grains  daily,  with 
good  effect.  Since  it  is  a  fact  that  at  times  there  are  syphilitic 
exudates  along  with  the  true  degenerative  process  in  tabes  dorsalis, 
this  kind  of  treatment  will  occasionally  give  some  good  results.  In 
the  great  majority  of  cases,  however,  mercury  and  potash  do  no  good 
and  they  may  actually  do  harm  by  hastening  on  the  downward  course 
of  the  disease;  hence  mercury  in  particular  should  be  given  with 
great  watchfulness,  and  if  improvement  does  not  appear  within  six 
weeks  it  should  be  suspended.  My  own  experience  and  the  careful 
investigations  of  my  friend,  Dr.  Collins,  show  that  antisyphilitic 
treatment  pursued  at  the  time  of  infection  may  hasten  the  onset  of 
the  disease.  It  has  been  observed  by  others  also  that  excessive  mer- 
curization  tends  to  produce  a  neurasthenic  state  most  prejudicial  to 
the  patient  and  one  which  may  even  lead  to  a  certain  amount  of 
neuritis.  When  the  physician  has  assured  himself  that  any  possi- 
bility of  relief  from  mercurials  or  iodide  is  not  to  be  hoped  for,  these 
drugs  should  be  dropped;  if  they  do  benefit  the  patient,  they  should 
be  repeated  at  intervals  of  three  months.  Along  with  these  first 
medicinal  measures,  the  physician  should  prescribe  something  which 
is  much  more  important,  and  that  is  simply  rest.  Every  patient 
with  locomotor  ataxia  should  at  once  have  the  importance  of  rest 
strongly  impressed  upon  him,  and  the  prescription  of  sixteen  weeks 


THE   DEGENERATIVE    DISEASES   OF   THE    SPINAL   CORD.        293 

in  bed  is  sometimes  advisable.  Equally  good  results  can  be  usually 
obtained,  however,  by  obliging  the  patient  to  go  through  a  simplo 
and  regular  life,  involving  no  walking  and  no  work.  Institutional 
life  for  three  months  is  of  enormous  advantage.  It  is  a  rule  to 
which  I  have  seen  hardly  an  exception  that  tabetic  patients  brought 
to  the  hospital  improve  in  a  striking  way  simply  from  the  quiet 
routine  of  life  there,  and  despite  the  thinness  of  city  milk  and  the 
odorous  strength  of  hospital  eggs. 

The  drugs  which  are  at  this  time  used  to  help  in  the  cure  are 
mainly  the  nitrate  of  silver,  the  tincture  of  iron,  the  preparations 
of  phosphorus.  I  have  not  been  able  to  convince  myself  that 
arsenic,  strychnine,  gold,  ergot,  barium,  or  aluminium  do  any  good, 
although  these  drugs  are  all  recommended  by  high  authorities. 
The  various  preparations  of  the  phosphates,  such  as  glycerin  phos- 
phate of  lime,  the  hypophosphites  of  lime,  phosphoric  acid,  seem 
to  me  to  be  of  some  benefit.  Strychnine  occasionally  does  good  in 
small  doses,  but  in  large  doses  it  may  lead  to  disastrous  results  and 
it  should  always  be  given  with  caution.  A  great  many  other  drugs 
may  be  given  for  the  relief  of  symptoms.  For  the  pain,  phenacetin 
is  the  drug  which  gives  the  most  satisfaction  excepting  morphine.  It 
may  be  combined  with  bicarbonate  of  sodium,  with  codeine,  or  with 
some  of  the  other  coal-tar  products,  such  as  antipyrin,  antifebrin, 
etc.  A  teaspoonful  of  baking-soda  internally  will  sometimes  stop 
the  pains.  Hoffman's  anodyne  and  cannabis  indica  may  be  tried. 
For  the  bladder  trouble,  the  fluid  extract  of  buchu  in  doses  of  twen- 
ty drops,  combined  with  ten  drops  of  the  tincture  of  hyoscyamus, 
18  very  helpful.  Small  doses  of  strychnine  may  be  combined  with 
this.  Small  amounts  of  strychnine  can  always  be  given  for  the 
sexual  weakness,  but  the  dose  should  never  be  made  a  large  one. 
For  the  gastric  crises,  nothing  is  so  good  as  a  hypodermic  injection 
of  morphine,  and  for  the  severe  cnses  of  pain  an  occasional  hypo- 
dermic of  morphine  should  be  given.  The  locomotor  ataxic,  how- 
ever, who  becomes  addicted  to  the  use  of  morphine  for  his  pains 
is  indeed  in  a  hopeless  condition.  In  persistent  constipation  the 
diet  should  be  light  and  mainly  of  liquids  such  as  milk,  malted 
milk,  broths,  etc.  In  persistent  diarrhceal  states  I  have  found  ioh- 
thyol  of  use.     This  drug  also  relieves  the  pains. 

The  annoying  insomnia  is  to  be  treated  by  fresh  air  and  seashore 
life.  If  drugs  must  be  used,  bromide  of  lithium  with  a  few  grains 
of  chloral,  and  paraldehyde  in  not  over  thirty-drop  doses,  are  the 
best. 

In  neuralgia  of  the  rectum  and  bladder,  suppositories  containing 
iodoform  and   belladonna,  or  codeine,  or  antipyrin,  may  be  used. 


294  DISEASES   OF   THE   KERVOUS   SYSTEM. 

Sometimes  simple  gelatin  or  gluten  suppositories  act  very  well. 
Some  of  the  cases  of  rectal  neuralgia  or  hyperesthesia  are  due  to  in- 
sufficient clearing  of  the  lower  bowel  when  a  movement  occurs,  and 
if  the  patient  washes  out  the  bowel  with  a  pint  of  warm  water  after 
each  movement  he  is  very  much  more  comfortable. 

There  is  no  diet  which  has  a  specific  effect  upon  locomotor 
ataxia,  but  the  patient  should  be  given  those  foods  which  are  non- 
fermentative  and  digestible.  Nitrogenous  and  fatty  foods  should 
be  prominent. 

Hydrotherapy  is  of  considerable  benefit.  The  most  efficient  of 
the  single  measures  is  the  lukewarm  bath  at  a  temperature  of  about 
95°  F.  for  ten  or  twenty  minutes  daily.  After  the  bath  it  is  well  to 
have  a  little  cold  water  poured  over  the  back  and  then  the  patient 
should  be  diligently  rubbed.  In  most  cases  a  simple  lukewarm  bath 
is  quite  as  effective  as  anything.  In  others  the  patient  feels  better 
if  there  is  added  to  it  some  slight  stimulant  to  the  skin — a  table- 
spoonful  of  pine-needle  extract,  or  a  regular  pine-needle  bath  may  be 
given.  The  Charcot  douche  given  in  moderate  strength  is  helpful 
in  cases  that  are  not  advanced  or  particularly  weak.  I  have  some 
hesitation  in  recommending  any  special  watering-places  or  cures.  I 
have  had  patients  return  benefited  from  the  Hot  Springs  of  Vir- 
ginia and  other  American  resorts.  In  Europe,  the  baths  at 
Lamalou,  France,  and  at  Nauheim,  Germany,  have  some  reputation. 
Hot  baths  are  sometimes  injurious,  and  bathing  may  be  overdone 
by  the  ataxic. 

Electricity  is  of  use  from  its  general  tonic  and  reflex  effects, 
and  perhaps  exercises  some  direct  influence  011  the  diseased  process. 
Strong  galvanic  currents  (15  to  30  ma.)  should  be  applied  along  the 
spine,  through  the  trunk,  and  down  the  legs  and  arms.  The  com- 
bined galvanic  and  faradic  current  is  even  better,  given  in  the  same 
way.  The  faradic  brush  should  be  applied  over  the  extremities  and 
along  the  back. 

The  actual  cautery  is  efficient  in  stopping  pains.  It.  should  be 
applied  to  the  back  as  often  as  twice  a  month  at  least  and  sometimes 
twice  a  week.  Dry  cups  may  be  applied  rapidly  and  in  great  number 
(80  to  100)  along  the  spine  and  along  the  course  of  the  sciatic  nerves. 
In  very  painful  cases  occasional  wet  cups  and  leeches  are  useful. 
Blisters  and  various  forms  of  counter-irritant  sometimes  do  good. 

Suspension  by  the  neck  and  arms  is  helpful  in  some  cases.  It 
is  best  adapted  to  persons  in  the  second  stage  and  to  those  who  have 
a  good  deal  of  bladder  trouble  and  pain.  It  is  of  little  value  in  the 
paralytic  stage,  and  must  be  used  with  care  in  the  early  stage  and 
when  patients  are  large  and  heavy.      Suspensions  should  be  given 


THE    DEGENERATIVE    DISEASES   OF   THE    SPINAL    CORD.        295 

for  from  one  to  three  minutes  three  times  a  week  until  twenty-five  or 
thirty  are  taken.  After  three  months  a  second  course  may  be  given. 
The  treatment  of  locomotor  ataxia  by  systematic  exercises,,  known 
as  the  Fraenkel  method,  is  one  that  of  late  has  been  considerably 
used.  It  consists  in  having  the  patient  go  though,  regular  exer- 
cises which  teach  him  to  co-ordinate  the  different  groups  of 
muscles  of  the  trunk,  legs,  and  arms.  A  list  of  the  exercises  such 
as  I  have  used  for  some  time  is  given  in  the  Appendix.  The 
Fraenkel  method  is  one  which  can  be  used  w^ch  advantage  with  per- 
sons Avho  are  passing  into  the  second  stage  of  tabes  and  in  whom 
the  disease  is  not  making  progress.  It  often  enables  the  patient  to 
walk  better  and  use  his  arms  better,  but  it  does  not  especially  affect 
the  progress  of  the  disease. 

Finally,  it  has  seemed  to  me  that  those  sufferers  from  locomotor 
ataxia  do  best  who  persistently  and  courageously  fight  against  their 
malady.  Those  who,  despite  suffering  and  discomfort,  will  three  or 
four  times  a  year  take  some  form  of  treatment,  medicinal,  hydro- 
therapeutic,  or  electric,  such  as  will  have  some  beneficial  effect  upon 
their  general  nutrition,  and  such  as  will  buoy  up  their  hopes  and  im- 
prove their  mental  condition,  are  quite  sure  to  be  rewarded  and 
after  a  hard  fight  emerge  into  a  state  of  comparative  relief  from 
their  symptoms  and  secure  a  measurable  degree  of  rest  from  the 
progress  of  their  disease. 

SPASTIC  SPINAL  PAKALYSIS  (Lateral  Spinal  Sclerosis). 
Little's  Disease. 

This  is  (a)  a  term  used  to  describe  a  form  of  paraplegia  caused  by 
chronic  myelitis,  and  (b)  a  congenital  disorder,  known  as  Little's 
disease,  in  which  there  is  sclerosis  of  the  lateral  columns  of  the 
cord. 

The  special  interest  attached  to  this  form  of  disease,  on  account 
of  the  controversies  concerning  it,  leads  me  to  say  a  few  words 
about  its  history.  Between  the  years  1846  and  1877  an  English 
Burgeon,  Little,  published  a  number  of  articles  on  a  disorder 
which  he  termed  "congenital  spastic  rigidity  of  the  limbs."  In 
1873  and  again  in  1879,  Dr.  E.  C.  Seguin,  of  New  York,  described 
a  condition  which  he  termed  "tetanoid  paraplegia."  After  the 
first  article  of  Dr.  Seguin,  to  whom  priority  belongs,  Professor  Erb 
and  Professor  Charcot  independently  published  articles  in  the  year 
1876  upon  what  Erb  called  "spasmodic  spinal  paralysis"  and 
Charcot  "spasmodic  dorsal  tabes." 

Starting  from  the  writings  of  these  three  authorities,  there  de- 
veloped in  the  course  of  a  few  years  a  description  of  the  disease 


296  DISEASES    OF   THE    NERVOUS   SYSTEM. 

which  became  known  as  "  spastic  spinal  paralysis"  or  "  lateral 
sclerosis."  This  for  a  long  time  was  accepted  as  an  independent 
malady  by  most  writers.  Of  late  years,  however,  its  real  existence 
has  been  strenuously  denied,  and  the  cases  supposed  to  represent 
this  disease  were  asserted  to  be  either  forms  of  dorsal  myelitis  or  the 
result  of  some  cerebral  defect.  Recently  both  French  and  Ger- 
man writers  have  revived  the  work  of  Little,  and,  having  supple- 
mented his  observations  with  their  own,  have  rehabilitated  spastic- 
paralysis  into  a  separate  disease  again,  giving  it  the  name  of 
"  Little's  disease."  * 

Etiology. — The  new  spastic  spinal  paralysis,  or  "  Little's  disease," 
is  an  affection  which  is  always  of  congenital  origin  and  is  due,  it  is 
supposed,  to  a  lack  of  development  of  the  pyramidal  tracts.  This 
lack  of  development  leads  to  a  sclerosis  of  the  lateral  columns  of  the 
spinal  cord  and  to  symptoms  of  rigidity  of  the  legs  and  arms,  exag- 
geration of  the  reflexes,  with  some  real  muscular  weakness  and 
atrophy.  The  disease  is  always  of  prenatal  or  natal  origin,  being 
due  to  some  developmental  defect  or,  as  Little  supposed,  to  prema- 
ture and  forced  deliveries.  It  may  also  be  a  hereditary  family  dis- 
ease. Through  these  causes  the  pyramidal  tracts  cease  to  grow, 
or,  at  least,  this  process  is  greatly  delayed. 

Symptoms. — The  malady  appears  within  a  short  time  after  birth, 
usually  within  a  year,  but  it  may  be  delayed  in  family  types  to  the 
fifth  year  or  even  later.  Some  cases  of  Little's  disease  may,  it  is 
believed,  develop  as  late  as  after  maturity.  It  is  not  my  purpose  to 
give  a  description  in  detail  of  the  symptoms  of  this  trouble,  because 
they  are  given  under  the  head  of  cerebral  diplegia  or  birth  palsy. 
The  only  difference  between  ordinary  cerebral  diplegia  and  the  dis- 
ease under  present  consideration  is  that  in  this  latter  form  there  are 
no  marked  mental  defects;  the  child  is  not  small  headed  and  idiotic, 
nor  does  it  have  epilepsy  or  cranial  nerve  palsy  or  hydrocephalus. 
The  brain  seems  to  be  spared  except  so  far  as  its  motor  functions 
are  concerned.  It  is  convenient  to  separate  this  type  of  disease 
from  the  ordinary  spastic  cerebral  palsies  with  mental  defect,  for  the 
reason  that  the  future  of  these  cases  is  in  some  instances  more  hope- 
ful. As  they  mature,  the  lateral  columns  occasionally  gain  in  de- 
velopment and  some  increase  in  the  strength  and  control  of  the 
limbs  is  obtained.     I  base  this  statement  upon  the  experience  of 

*  Sometimes  a  spastic  paraplegia  develops  quickly  ;  after  a  few  weeks 
the  symptoms  improve  and  the  patient  gets  well ;  this  has  been  called  "hyper- 
tonic paralysis.  "  There  is  here,  however,  simply  a  slight  grade  of  myelitis 
or  meningo-myelftis,  and  n©  separate  name  is  required  to  show  what  is  the 
matter. 


THE    DEGENERATIVE    DISEASES    OF   THE   SPINAL    COED.        297 

others.  In  several  cases  of  Little's  disease  at  the  age  of  fifteen  to 
twenty-five  which  I  have  seen,  there  has  been  no  marked  improve- 
ment.    Mentally,  however,  these  patients  are  often  very  bright.* 

Children  with  this  trouble  on  trying  to  walk  are  obliged  to  cross 
one  leg  in  front  of  the  other  as  they  are  helped  along,  giving  them 
a  characteristic  "  cross-legged"  progression.  The  arms  are  less 
affected  than  the  legs.  The  facial  and  throat  muscles  may  be 
slightly  involved.  There  is  no  pain.  In  some  cases  the  disability 
increases  as  the  child  grows  older,  owing  to  the  greater  size  and 
clumsiness  of  the  patient.  The  arms  become  much  stiffened  and 
contractured,  and  the  hands  are  flexed  so  that  the  patient  can 
neither  walk  nor  help  himself.  Epilepsy  and  mental  deterioration 
also  may  develop  at  the  time  of  puberty  or  adolescence. 

Prognosis. — The  mild  cases  that  learn  how  to  walk  and  can  use 
the  arms  and  hands  may  grow  up,  slowly  improving,  and  reach  a 
good  age  and  a  fair  degree  of  health.  The  severer  cases  rarely 
reach  adolescence,  but  grow  gradually  more  helpless  and  generally 
succumb  to  some  intercurrent  disease  before  they  are  twenty. 

Diagnosis. — The  disease  is  distinguished  from  ordinary  cerebral 
diplegia  (birth  palsy)  due  to  brain  lesion  by  the  absence  of  epilepsy, 
mental  defects,  and  microcephalus. 

From  compression  myelitis,  the  involvement  of  the  arms,  and 
the  absence  of  pain  and  disturbance  of  sphincters  are  distinctive. 
Hereditary  spastic  paraplegia  runs  in  families,  begins  at  the  fourth 
or  fifth  year,  and  involves  chiefly  the  legs. 

Treatment. — This  is  altogether  one  of  mechanics  and  attention 
to  nutrition.  The  limbs  must  be  persistently  massed;  tenotomies 
should  be  performed  so  as  to  straighten  the  legs ;  constant  voluntary 
effort  to  use  the  stiffened  muscles  should  be  made.  Braces,  roller 
crutches,  etc.,  should  be  used.  Patience  is  often  greatly  rewarded 
in  this  disease. 

Hereditaby  Spastic  Spinal  Paralysis. — Spastic  paralysis  in 
very  rare  cases  is  found  to  run  in  families,  affecting  different  mem- 
bers of  many  succeeding  generations.  In  the  cases  described,  it 
begins  at  about  the  age  of  five,  affects  only  or  mainly  the  legs,  runs 
a  very  slow  course,  is  not  accompanied  by  pain,  ataxia,  or  visceral 
symptoms;  and  runs  a  course  lasting  twenty  or  thirty  years.  Dr. 
Bayley,  of  Philadelphia,  has  described  a  family  of  typical  cases. 

*It  is  due  to  American  neurology  to  say  that  Dr.  Seguin  as  long  ago  as 
1879  said:  "  It  is  possible  that  tetanoid  paraplegia  in  young  children  may 
be  due  to  deflcienl  cerebral  development  and  consequently  agenesis  of  certain 
tracts  of  the  cord.  " 


298  DISEASES   OF   THE    NERVOUS   SYSTEM. 


THE  COMBINED   SCLEROSES. 

By  the  combined  scleroses  is  meant  those  forms  of  degenerative 
sclerosis  in  which  both  the  posterior  and  lateral  columns  are  in- 
volved. There  are  several  diseases  in  which  combined  sclerosis 
exists.     They  are : 

1.  Combined  scleroses  of  profoundly  anaemic  and  toxic  states 
(Putnam's  type). 

2.  Hereditary  spinal  ataxia  (Friedreich's  ataxia  and  hereditary 
ataxic  paraplegia) . 

3.  Combined  scleroses  complicating  general  paresis. 

4.  Accidental  forms  (Gower's  ataxic  paraplegia). 

There  are  many  cases  reported  in  literature  of  combined  scleroses 
but  the  clinical  pictures  vary  very  greatly.  These  cases  are  prob- 
ably in  the  most  part  forms  of  chronic  myelitis  or  meningo-myelitis 
with  ascending  and  descending  degeneration.  Marie  has  shown 
that  the  vascular  supply  of  the  spinal  cord  is  such  as  rather  to 
favor  the  development  by  extension  of  sclerosis  in  the  lateral  and 
posterior  columns  from  a  chronic  leptomeningitis,  and  his  sug- 
gestion that  many  of  these  cases  are  perhaps  of  syphilitic  origin  ac- 
cords with  my  experience  and  conviction.  Some  years  ago,  Gowers 
described  a  disease  that  he  called  ataxic  paraplegia,  the  lesion  in 
•which,  he  believed,  lay  in  the  lateral  and  posterior  columns.  Most 
of  the  cases  which  belong  to  this  clinical  description  I  think  can 
be  properly  classed  either  with  the  cases  of  locomotor  ataxia,  of 
multiple  sclerosis,  or  of  some  form  of  chronic  myelitis.  It  seems  to 
me,  therefore,  inadvisable  to  encumber  oui  neurology  with  a  descrip- 
tion of  this  disease.  There  is,  however,  a  hereditary  form  of  ataxia 
with  paraplegia  which  belongs  to  the  group  of  congenital  or  family 
diseases  and  is  closely  related  to  Friedreich's  ataxia;  and  there  is 
a  form  of  combined  sclerosis  in  which  some  ataxic  and  some  sensory 
and  motor  symptoms  develop  associated  with  pernicious  anaemia 
and  certain  other  cachectic  states,  but  neither  of  these  is  the  disease, 
commonly  spoken  of  as  ataxic  paraplegia  of  Gowers,  which  is,  I 
repeat,  no  disease  at  all.  Striimpell  and  many  others  have  reported 
cases  with  autopsies  showing  combined  scleroses,  but  there  is  no 
clinical  picture  that  can  yet  be  attached  to  such  findings  except  those 
I  have  above  indicated.  Hence,  of  all  the  combined  scleroses,  it 
is  only  hereditary  ataxia  and  the  combined  scleroses  of  anaemia 
that  have  practical  clinical  interest. 


THE    DEGENERATIVE    DISEASES   OF   THE    SPINAL   CORD.         299 


1.  The  Combined  Scleroses  of  Pernicious  Anjbmia  ahd 

Cachectic  States    (Putnam's  Type). 

This  form  of  disease,  not  so  rare  as  has  been  supposed,  was  first 
described  by  Dr.  J.  J.  Putnam,  later  by  myself ;  and  in  quite  recent 
times  has  been  expanded  and  placed  in  relation  with  pernicious 
anaemia  by  a  number  of  observers. 

Etiology. — In  the  original  cases  the  patients  were  mostly  women 
and  the  ages  ranged  from  forty-five  to  sixty-four  years.  Two  of 
my  cases  were  men,  one  was  a  woman ;  all  were  over  fifty  years  of 
age.  A  history  of  possible  lead  poisoning  was  obtained  by  Putnam. 
In  my  experience  profound  or  prolonged  malarial  toxaemia  was 
the  only  factor  I  could  discover.  The  causes  of  pernicious  anaemia 
must  be  placed  in  the  list  of  the  causes  of  this  form  of  sclerosis. 
Disease  of  the  suprarenal  capsules  and  probably  any  very  prolonged 
and  profound  toxaemic  state  may  lead  to  the  double  degeneration  of 
the  cord.  Not  all  cases  of  pernicious  toxaemia  or  anaemia,  however, 
cause  these  changes.  Hence  the  element  of  a  neuropathic  state 
must  be  admitted. 

Symptoms. — The  symptoms  begin  generally  with  numbness  of 
the  extremities,  followed  by  progressive  enfeeblement,  and  ending 
in  a  paraplegia.  Great  emaciation  and  auamiia  are  present,  and 
there  is  often  an  obstinate  diarrhoea.  ZSTo  paralysis  of  any  special 
groups  of  muscles  occurs  until  the  final  paraplegia  sets  in.  There  are 
in  some  cases  anaesthesia  and  ataxia,  but  spastic  symptoms,  with  ex- 
aggerated knee  jerk  and  ankle  clonus,  are  the  more  common.  Lan- 
cinating or  girdle  pains  are  very  rare.  The  arms  are  affected,  but 
less  than  the  legs.  The  visceral  centres  are  not  affected  till  late. 
The  vision  and  other  special  senses  and  speech  are  not  disturbed. 
Mental  symptoms  approaching  dementia  occur  in  the  terminal  stages 
in  some  cases. 

The  general  course  is  that  of  a  rather  rapidly  progressive  affec- 
tion causing  parsesthesia  and  sometimes  anaesthesia  of  the  extremi- 
ties, especially  the  lower,  with  progressive  weakness  of  the  extremi- 
ties. This  is  associated  with  very  profound  anaemia,  general 
muscular  emaciation,  diarrhoea,  ending  in  a  paraplegia. 

"Pathological  Anatomy. — The  pathological  appearances  of  the 
spinal  cord  as  described  by  Putnam  correspond  to  my  own  observa- 
tions: in  all  the  cases  two  sets  of  changes  in  the  cord  are  recogniz- 
able: one  of  older  date,  consisting  in  a  relatively  dense  sclerosis  in 
the  posterior  columns  and  in  the  lateral  columns  (mainly  confined  to 
the  pyramidal  tracts)  ;  and  one  of  subacute  character,  and  evidently 
of  quite  recent  occurrence.  This  subacute  process  is,  as  regards 
the  white  columns,  partly  in  new  tracts,  parti"  around  the  borders 
of  the  more  dense  sclerosis,  and    is  chiefly  characterized  by   the 


300  DISEASES    OF   THE    XERYOUS   SYSTEM. 

peculiar  perforated  appearance  which  indicates  a  somewhat  rapid 
destruction  of  nerve  tubes,  with  the  oedematous  distention  or 
destruction  of  the  intervening  septa,  associated  with  the  formation 
of  granule  cells. 

In  the  gray  horns  the  degenerative  change  (partly  recent,  partly 
of  older  date)  is  indicated  by  a  disintegration  of  nerve  cells. 

In  the  cases  of  distinctly  pernicious  anaemia  the  terminal  soften- 
ing is  not  described  and  there  is  only  a  well-marked  sclerosis  in- 
volving the  posterior  and  lateral  columns  and  more  marked  in  the 
upper  regions  of  the  cord  (Fig.  138). 

The  prognosis  is  not  good,  but  there  are  more  favorable  cases 
than  those  first  observed,  and  I  have  a  patient  who  has  kept  fairly 
well  for  over  six  years.      Two  others  died  within  two  years. 

The  diagnosis  is  based  upon  the  age  of  the  patient,  the  presence 
of  profound  anaemia  and  perhaps  of  a  malarial  history,  the  parees- 


Fig.  13R.—  The  Spinal  Cord  in  Combined  Sclerosis  from  Pernicious  Anemia,  Dorsal 
Re<;ion.     The  columns  of  Goll,  crossed  pyramidal  tracts,  and  cerebellar  tracts  are  affected. 

thesia,  slight  ataxia,  marked  and  progressive  weakness  and  emacia- 
tion, tendency  to  obstinate  diarrhoea,  and  finally  the  rather  sudden 
paraplegia. 

The  treatment  should  consist  of  quinine,  arsenic,  iron,  bone 
marrow,  and  possibly  suprarenal-capsule  extract.  Besides  this, 
the  patient  should  have  the  most  nourishing  food  and  a  stimulat- 
ing air,  free  from  malaria. 

Hereditary  Spixai,  Ataxia  (Friedreich's  Ataxia). 

Introduction. — There  are  three  forms  of  ataxia  of  congenital  and 
often  family  origin.  They  are:  Hereditary  spinal  ataxia,  or  Fried- 
reich's ataxia,  hereditary  cerebellar  ataxia,  and  hereditary  ataxic 
paraplegia.  They  are  quite  similar  in  cause  and  mode  of  develop- 
ment. The  difference  in  symptoms  depends  upon  the  fact  that  the 
defect  develops  in  the  one  case  mainly  in  the  posterior  and  lateral 
columns  of  the  cord,  in  the  second  in  the  cerebellum,  and  in  the  third 
mainly  in  the  lateral  columns. 


THE    DEGENERATIVE    DISEASES    OF   THE   SPINAL    CORD.        301 

Friedreich^  ataxia,  the  most  common  of  all  the  forms,  is  a 
chronic  degenerative  disease  mainly  affecting  the  posterior  and 
lateral  columns  of  the  cord. 

Clinically  the  disease  is  characterized  by  ataxia  beginning  in  the 
lower  limbs  and  gradually  involving  the  upper  limbs  and  the  organs 
of  speech.  Curvature  of  the  spine,  talipes,  vertigo,  anj  finally  pa- 
ralysis and  contractures  appear.  The  knee  jerk  is,  as  a  rule,  absent. 
There  is  but  little  pain  or  anaesthesia,  and  optic  atrophy  and  visceral 
troubles  are  usually  absent. 

Etiology. — The  fundamental  factor  in  predisposition  is  an  in- 
herited or  connate  lack  of  development  of  the  spinal  cord,  more  par- 
ticularly of  the  posterior  columns  and  pyramidal  tracts.  This  condi- 
tion is  inherited  directly  sometimes,  but  indirectly  as  a  rule ;  that 
is  to  say,  the  parents  or  other  members  of  the  family  usually  show 
simply  a  neurotic  history,  and  it  is  in  only  a  minority  of  cases  that 
there  is  a  history  of  ataxia  in  the  direct  line  of  ancestry. 

The  more  frequent  condition  is  this:  the  parents  or  grand- 
parents have  some  neuroses,  such  as  insanity,  inebriety,  or  great 
nervous  irritability ;  then  the  ataxia  occur  in  the  children  of  the  next 
generation.  Sometimes  in  a  single  family  the  uncles  and  nephews 
or  cousins  may  be  found  to  have  the  disease.  Hence  the  name 
"family  ataxia,"  used  by  some  writers.  There  are  a  good  many 
cases  in  which  the  parents  were  apparently  perfectly  sound  and 
healthy.  Yet  it  is  most  probable  that  the  sufferers  from  Fried- 
reich's disease  inherit  a  tendency  to  degenerative  processes  from 
some  of  their  ancestors.  This  degenerative  tendency  may  have 
been  shown  in  those  ancestors  in  a  very  slight  degree.  The  pa- 
1  tents  rarely  have  locomotor  ataxia,  though  this  has  been  observed 
in  a  few  cases.  The  children  of  locomotor  ataxics  do  not  have 
Friedreich's  ataxia  except  in  the  very  rarest  instances. 

Syphilis  in  the  parents  is  an  element  in  some,  probably  in  most 
cases.  Habitual  intemperance  in  parents  undoubtedly  is  a  factor 
sometimes;  much  more  rarely  consanguinity  and  tuberculosis  act  as 
predisposing  causes  of  degeneration. 

More  cases  have  been  observed  in  America  than  in  any  other 
country;  while  the  fewest  have  been  reported  from  France.  The 
disease  develops  at  about  the  time  of  puberty,  most  cases  occurring 
between  the  ages  of  six  and  fifteen  years.  It  is  not  very  rare,  how- 
ever, for  symptoms  to  develop  even  in  infancy,  though  some  of  the 
reported  at  this  time  were  probably  of  a  syphilitic  character. 
In  a  given  family  the  disease,  as  a  rule,  strikes  the  older  members 
first,  but  the  younger  members  are  attacked  at  a  relatively  earlier 
age.     The  most  typical  time  of  development  is  a  rather  late  one,  i.e., 


302 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


after  twelve  years  of  age.  The  disease  may  come  on  after  maturity. 
In  American  cases  the  age  of  development  of  the  disease  has  been 
rather  earlier  than  the  average.  The  male  sex  slightly  predom- 
inates, its  proportion  being  about  sixty  per  cent.  In  America  the 
female  sex  has,  however,  been  more  affected  (3  to  2).  The  patients 
are  the  children  of  the  laboring  and  agricultural  classes.  They 
have  been  found  in  the  country  oftener  than  in  crowded  cities.  The 
families  have  often  been  large,  but  this  is  not  always  the  case,  es- 
pecially in  American  cases.  Nursing  at  the  mother's  breast  is 
thought  to  have  been  an  exciting  cause.  Usually  the  disease  ap- 
pears after  infectious  fevers,  such  as  diphtheria,  variola,  and  typhoid. 

Symptoms.  —  The  patient 
first  notices  an  uncertainty  in 
the  gait  and  some  feebleness  in 
the  lower  limbs.  These  symp- 
toms gradually  increase  until 
they  interfere  seriously  with 
progression,  and  force  him  to 
leave  off  active  work.  With 
this  there  may  be  some  slight 
pains  or  numbness  in  the 
lower  limbs,  and  an  examina- 
tion will  show,  within  a  year 
or  earlier,  that  the  knee  jerk 
is  gone.  After  five  or  six  years 
the  arms  become  affected  with 
inco-ordination,  and  a  little 
later  bulbar  symptoms,  such 
as  thick  or  scanning  speech, 
and  often  nystagmus,  appear. 
During  this  time  the  patient  suffers  little  pain  and  has  no  trouble 
with  the  bladder  or  rectum.  Vertigo  and  headache  are  often  pres- 
ent. Dorsal  flexion  of  the  toes,  talipes  varus  or  some  other  form 
of  clubfoot,  and  lateral  curvature  of  the  spine  are  often  observed 
(Fig.  139).  Oscillation  of  the  head  and  choreiform  or  inco-ordi- 
nate  movements  of  the  extremities  may  develop.  As  the  disease 
progresses  the  legs  become  weaker,  and  finally  paraplegia,  witn 
contractures  and  muscular  wasting,  sets  in.  The  disease  makes  slow 
progress;  often  it  remains  almost  at  a  standstill  for  years,  and  the 
patients  usually  die  of  some  intercurrent  disease,  such  as  phthisis 
or  an  infectious  fever. 

Among  the  rarely  observed  symptoms  are  tremor,  spasms,  de- 
creased electrical  irritability,  muscular  atrophy,  vasomotor  paresis. 


Fig.  139.  —  Friedreich's  Ataxia,  showing 
deformities  of  legs  in  the  late  stage. 


THE    DEGENERATIVE    DISEASES    OF    THE    SPINAL    CORD.        303 

polyuria,  glycosuria,  anaesthesia,  fibrillary  tremor,  choking  attacks, 
ptyalism,  strabismus,  diplopia,   blepharospasm,  a  slight  degree  of 


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Fig.  140.— Spinal  Cokd  in  a  Long-standing  Case  of  Hereditary  Ataxia,  Cervical, 
Dorsal,  and  Sacral  Regions.  Besides  the  sclerosis,  the  cord  is  filled  with  small  vacuoles 
ifcich  are  dilated  perivascular  spaces. 


304  DISEASES   OF   THE   XERVOUS   SYSTEM. 

ptosis,  sluggish  pupils,  tachycardia,  profuse  sweats,  impotence, 
slight  vesical  incontinence,  fragilitas  ossiuni.  Many  of  these  symp- 
toms are,  however,  exceptional  and  accidental. 

The  major  and  essential  symptoms  are :  (1)  ataxia,  beginning  in 
the  lower  limbs  and  extending  to  the  arms  and  tongue;  (2)  peculiar 
rolling,  ataxic  gait,  ataxia gradully  involving  the  amis;  (3)  disturb- 
ances of  speech;  (4)  talipes  and  spinal  curvatures;  (5)  gradual  de- 
velopment of  paraplegia;  (G)  loss  of  knee  jerk;  (7)  absence  of 
cutaneous  anaesthesia,  of  bladder  troubles,  of  eye  troubles  except 
nystagmus,  and  of  severe  pains;  (8)  the  development  of  the  fore- 
going at  about  the  time  of  puberty. 

Pathology. — The  lesions  of  importance  are  found  in  the  spinal 
cord  and  medulla  only.  The  cord  is  usually  small,  flattened,  and 
apparently  congenitally  imperfect  in  development.  In  some  cases 
two  central  canals  have  been  seen.  A  sclerosis  exists  throughout  the 
whole  length  of  the  posterior  and  lateral  columns,  sometimes  extend- 
ing to  the  anterior  columns  (Fig.  140) .  The  sclerosis  is  most  marked 
in  the  postero-median  columns,  which  are  always  affected  in  toto. 
The  postero-external  column  is  less  involved  and  there  is  often  a 
narrow  strip  of  healthy  tissue  between  the  posterior  horn  and  the 
sclerosed  area,  also  between  the  posterior  gray  commissure  and  the 
diseased  parts.  The  posterior-column  sclerosis  is  usually  most 
marked  in  the  lu;  .ibar  region.  In  the  lateral  columns  the  sclerosis 
always  affects  the  crossed  pyramidal  tracts.  The  direct  cerebellar 
tracts  and  the  so-called  ascending  antero-lateral  tract  are  diseased 
in  some  cases,  but  apparently  not  in  all.  In  a  few  instances  the 
anterior  median  columns  are  involved.  A  zone  of  healthy  tissue  is 
often  found  between  the  sclerosed  pyramidal  tracts  and  the  posterior 
horn.  There  are  no  important  changes  in  the  gray  matter.  Some 
chronic  leptomeningitis,  especially  on  the  posterior  surface,  has 
been  noted.  The  medulla  shows  some  traces  of  extension  of  the 
sclerosis,  but  the  involvement  of  the  cells  of  the  hypoglossal  nucleus 
is  probably  the  most  significant  change.  The  brain  exhibits  no 
changes  of  importance  in  relation  to  the  symptomatology  of  the  dis- 
ease. The  posterior  nerve  roots  are  extensively  sclerosed,  the  an- 
terior roots  less  so,  and  the  peripheral  nerves  show  some  degenera- 
tive changes.  The  peripheral  nerves  are  much  less  involved  than 
in  tabes  dorsalis.  It  is  asserted  that  the  sclerosis  in  the  cord  is 
really  a  neuroglia  proliferation — a  gliosis— and  there  is  no  doubt  a 
large  amount  of  neuroglia  proliferation  in  the  diseased  areas. 
Curious  vacuoles  were  found  in  one  case  examined  by  myself. 
They  were  due  to  dilated  perivascular  spaces  (Pig.  140  j. 

Course  and  Prognosis.— The  disease  is  a  progressive  one,  though 


THE    DEGENERATIVE   DISEASES   OF   THE   SPINAL    CORD.        305 

it  may  be  stationary  for  a  long  time  and  may  even  show  temporary 
improvement.  The  longest  period  of  duration  of  the  disease  on 
record  is  forty-six  years  and  the  shortest  two  years,  the  average 
being  fifteen  or  twenty  years.  Death  occurs  from  some  intercurrent 
disorder. 

Treatment. — A  quiet  life,  good  food,  and  favorable  hygienic 
surroundings  are  the  main  therapeutic  helps.  Arsenic  and  various 
nerve  tonics  may  be  of  temporary  benefit.  My  cases  and  some  of 
the  French  cases  were  benefited  by  suspension  by  the  neck  in  a  Sayre 
apparatus.  If  the  disease  appears  in  one  member  of  a  family, 
effort  should  be  made  to  prevent  its  appearance  in  others.  The 
infant  should  not  be  nursed  by  its  mother;  special  care  should  be 
taken  to  prevent  its  getting  any  infectious  fevers  and  to  prevent  it 
from  receiving  any  falls  or  blows.  Its  life  should  be  exceptionally 
quiet,  so  far  as  physical  exertion  goes. 

3.   Hereditary  Ataxic  Paraplegia. 

This  is  a  hereditary  disease  and  sometimes  a  family  one.  In  six 
cases  observed  by  myself,  there  were  no  other  instances  in  the  fami- 
All  my  patients  were  young  women.  The  disease  began  be- 
tween the  ages  of  twelve  and  sixteen,  but  sometimes  the  patients 
could  remember  that  they  had  never  been  so  quick  of  foot  as  other 
girls.  A  neurotic  heredity  existed,  but  no  syphilis  or  alcoholism. 
The  exciting  cause  is  not  known. 

The  disease  begins  with  a  stiffness  and  weakness  of  the  legs, 
iated  with  this  is  a  decided  ataxia.  This  is  occasionally  more 
cerebellar  than  spinal,  but  in  most  cases  it  is  shown  by  awkwardness 
in  posing  and  in  moving  the  limbs  in  different  definite  directions, 
and  in  walking  a  line.  There  are  decided  exaggeration  of  reflexes 
and  ankle  clonus,  but  no  painful  spasms,  no  pains,  and  no  distinct 
anaesthesia;  there  is  some  pareestnesia.  The  trouble  is  much  the 
most  marked  in  the  legs,  but  the  arms  are  slightly  involved,  the 
■  fa<e  and  cranial  nerves  not  at  all.  In  one  case  optic  neuritis  was 
present. 

The  sphincters  are  not  involved,  the  general  nutrition  is  good,  the 
mind  is  clear.  The  disease  in  most  cases  progresses  very  slowly. 
One  of  my  patients  is  married  and  continues  in  fair  health. 

In  some  cases,  evidences  of  degeneration  and  breaking  up  of 
nerve  centres  occurs,  just  as  in  the  terminal  state  of  Friedreich's 
ataxia.  However,  I  have  one  patient  who  has  had  the  disease  in  a 
mild  form  for  twenty  years  and  is  now  quite  comfortable. 

Hereditary  ataxic  paraplegia  is  more  allied  to  the  spastic  para- 
20 


306  DISEASES   OF   THE    NERVOUS   SYSTEM. 

plegias  than  to  Friedreich's  disease,  and  it  has,  like  that  malady, 
a  rather  more  favorable  course — so  far  as  my  limited  experi- 
ence shows.  I  know  of  no  autopsies  made  on  these  cases,  but  the 
symptoms  point  to  a  defect  of  the  lateral  columns  and  of  either 
the  cerebellum  or  the  posterior  columns. 

4.  Hereditary  Cerebellar  Ataxia. 

Though  not  belongiug  in  the  group  of  spinal  diseases,  hereditary 
cerebellar  ataxia  is  so  closely  related  to  those  hereditary  forms  I 
have  just  been  describing  that  I  deem  it  best  to  give  an  account  of 
it  here. 

This  is  a  chronic  disease  beginning  in  early  life,  usually  of 
hereditary  or  congenital  origin,  and  characterized  by  an  ataxia  of 
cerebellar  type  associated  with  symptoms  indicating  the  involvement 
of  some  of  the  cranial  nerves.  In  course  and  symptoms  it  resembles 
to  some  extent  hereditary  spinal  ataxia  and  belongs  to  the  same  class 
of  diseases.  The  names  of  Fraser,  Nonne,  and  Marie  are  connected 
with  the  first  descriptions  of  this  disorder  and  its  differentiation 
from  hereditary  spinal  ataxia. 

Etiology. — The  malady  begins  in  early  life  between  the  ages  of 
ten  and  thirty,  developing,  therefore,  somewhat  later  than  Fried- 
reich's ataxia.  The  disease  occurs  rather  more  often  in  males  than 
in  females,  but,  like  other  family  diseases,  is  usually  transmitted  by 
the  female.  Syphilis  and  a  neuropathic  constitution  in  the  female 
have  been  noted  in  a  number  of  cases. 

Symptoms. — The  first  symptom  is  shown  in  a  disturbance  of  the 
gait.  This  is  indicated  by  clumsiness  and  stumbling  and  by  a  ten- 
dency to  rolling  and  pitching  like  a  drunken  man.  The  patient  tends 
to  walk  with  the  feet  wide  apart.  He  does  not,  however,  show  the 
"Romberg  symptom;"  that  is,  he  can  stand  fairly  well  with  the  feet 
together  and  the  eyes  shut.  There  are  inco-ordination  and  jerkiness 
in  the  movements  of  the  arms  and  sometimes  choreic  movements. 
He  sometimes  also  has  oscillation  and  jerky  movements  of  the  head. 
When  lying  down  the  inco-ordination  is  very  much  lessened.  The 
speech  is  hesitating,  ataxic,  and  explosive.  The  eyes  show  jerky 
movements  somewhat  like  those  in  nystagmus.  An  important 
symptom  in  many  cases  is  the  development  of  optic  neuritis  followed 
by  optic  atrophy  and  blindness.  The  knee  jerks  are  usually  exag- 
gerated. The  patient  has  no  anaesthesia  and  suffers  little  pain,  al- 
though he  may  have  some  headache.  There  is  no  disturbance  of 
the  sphincters.  Mentally  the  patients  are  usually  somewhat  defi- 
cient, becoming  either  simply  childish  or  actually  demented.     The 


THE    DEGENERATIVE   DISEASES   OF   THE    SPINAL    CORD.        307 

malady  progresses,  although  not  always  steadily,  the  disease  some- 
times remaining  stationary  for  some  years.  Eventually,  however, 
the  patient  becomes  bedridden  and  dies  of  exhaustion. 

Pathological  Anatomy. — The  few  autopsies  which  have  been 
made  show  an  atrophy  of  the  cerebellum.  In  some  cases  this  is 
macroscopic,  the  cerebellum  being  reduced  to  one-half  or  one-third 
its  size.  In  other  cases  there  is  no  naked-eye  change,  but  there  is 
found  microscopically  an  atrophy  of  the  cells  of  Purkinje. 

Diagnosis. — The  disease  has  not  yet  been  sufficiently  studied  to 
enable  one  always  to  recognize  it  positively.  Indeed,  it  is  not  un- 
likely that  there  are  mixed  or  transitional  forms  of  hereditary  cere- 
bellar and  hereditary  spinal  ataxia.  Furthermore,  it  is  probable 
that  in  some  cases  small  hemorrhages  or  nodules  of  sclerosis  may 
occur  after  fevers  during  childhood,  which  may  lead  to  the  develop- 
ment of  symptoms  resembling  the  hereditary  malady.  However, 
the  points  of  diagnosis,  as  far  as  established,  consist  in  the  heredi- 
tary history  or  family  history  of  this  malady.  ]N"ext  is  the  fact  that 
it  develops  gradually,  beginning  writh  the  ataxia  characteristic  of 
the  cerebellar  disease,  but  involving  the  arms  as  well  as  the  legs. 
Again,  there  is  always  an  increase  of  knee  jerks,  whereas  in 
spinal  ataxia  these  are  lost.  Then  we  find  in  this  malady  no  pain 
or  anaesthesia  in  the  legs,  and  no  involvement  of  the  sphincters. 
The  occurrence  of  optic  atrophy  and  of  mental  defect  help  much  to 
differentiate  the  disease  from  other  types. 

Treatment. — The  disease  is  a  progressive  one  and  little  can  be 
done  but  to  attend  to  the  general  nutrition  of  the  patient.  In  one 
case,  however,  seen  by  me  with  Dr.  Still  well,  it  was  found  that  the 
continuous  use  of  antipyrin  was  accompanied  by  an  amelioration  of 
symptoms  and  seemed  really  to  help  the  patient  a  great  deal. 


CHAPTER  XV. 

THE  PROGRESSIVE  MUSCULAR  ATROPHIES  AND 
MUSCULAR  DYSTROPHIES. 

The  result  of  modern  studies  is  to  show  that  the  anterior  cornual 
cells  of  the  spinal  cord,  the  motor  nerves  and  their  terminal  end 
organs,  the  muscles,  form  a  trophic  unit,  and  that  the  same  degen- 
erative disease  may  attack  either  end  or  any  part  of  this  physio- 
logical mechanism.  There  is  a  clinical  and  pathological  unity  in 
all  the  different  spinal  and  muscular  types  of  atrophies.  But  there 
are  sufficient  differences,  also,  to  oblige  us  for  convenience'  sake  to 
make  certain  classifications.  Thus  those  disorders  which  attack 
chiefly  and  first  the  anterior  horn  cells  and  the  pyramidal  tract  are 
called  progressive  muscular  atrophies}  those  disorders  attacking  first 
the  muscle  tissue  and  its  nerves  are  called  progressive  muscular 
dystrophies  (Fig.  141).  The  progressive  muscular  atrophies  of 
central  origin  may  attack  the  motor-nerve  cells  of  the  eye,  of  the 
throat  and  lips,  of  the  upper  or  lower  spinal  cord.  In  accordance 
with  the  level  affected  the  disease  has  received  different  names. 
Sometimes  the  pyramidal  tracts  of  the  spinal  cord  are  first  and  most 
involved.  This  has  furnished  excuse  for  another  type.  Then, 
again,  while  most  cases  of  muscular  atrophy  are  acquired,  there  is 
one  type  of  it  which  is  a  hereditary  one.  Thus  we  find  the  disease 
classified  as  follows : 

f  Progressive  ophthalmoplegia. 
Progressive    muscular   |  Progressive  bulbar  palsy, 
atrophies    of  spinal  i   Progressive  muscular  atrophy, 
or  nervous  origin.        i  Progressive  hereditary  muscular  atrophy  (leg  type). 

[_  Amyotrophic  lateral  sclerosis. 

The  progressive  muscular  dystrophies  have  also  been  much  sub- 
divided, but  they  are  essentially  the  same  disease,  as  will  be  seen 
later. 

Of  the  muscular  atrophies,  I  have  already  described  ophthal- 
moplegia. 


MUSCULAR    ATROPHIES    AND    DYSTROPHIES. 


309 


Progressive  Muscular  Atrophy  (Progressive  Spinal 
Amyotrophy;  Dcchenxe-Arax's  Disease). 

This  is  a  disease  characterized  by  a  slow,  progressive  atrophy 
of  the  muscles  of  the  extremities  and  trunk,  with  consecpient 
paralysis,  not  accompanied  by  any  notable  sensory  disturbance, 
and  due  to  a  progressive  atrophy  of  the  motor  and  trophic  cells  in 
the  spinal  cord. 

Etiology. — The  disease  affects  persons  in  the  middle  period  of 
life  (twenty-five  to  forty-five).  The  extremes  are  fourteen  and 
seventy  years  (Gowers).  It  is  more  frequent  in  males.  Heredity 
is  rarely,  if  ever,  a  factor.  Great  mental  strain,  exposure,  trauma- 
tism, excessive  use  of  certain  groups  of  muscles,  acute  infectious 
diseases— especially    typhoid,   measles,    cholera;  childbirth,   acute 


1.  ~'. 

Vw.  141. — Showi.m;  :  1.  Segment  of  spinal  cord  with  anterior-horn  cell,  end  brush,  and 
lateral  tracts,  the  parts  affected  in  progressive  muscular  atrophies;  and  2,  the  muscle 
and  its  nerves,  the  parts  affected  in  progressive  muscular  dystrophies. 

rheumatism,  syphilis,  and,  more  than  anything  else,  lead  poisoning 
are  causes.  It  may  complicate  locomotor  ataxia.  The  causes,  as 
may  be  seen,  are  much  the  same  as  those  of  bulbar  paralysis.* 

Symptoms.     The  patient  suffers  at  first  from  slight  rheumatoid 

*  Among  2H  of  my  cases  22  wen.-  males.  The  disease  began  between 
between  thirty-one  and  forty  in  10  cases  ;  between  twenty-one  and  thirty  in  7  ; 
in  5  it  developed  before  the  age  of  twenty  ;  and  in  2  after  the  age  of  fifty,  but 
in  more  after  sixty.  It  begins  rather  earlier  in  women.  In  the  majority, 
20,  tin' malady  began  in  hand  or  shoulder  and  ran  the  classical  course  ;  in 
3  it  began  In  the  legs  and  ascended;  iu  3  it  began  in  the  medulla;  and  in 

1  in  oculo-motor  nuclei,  speedily  extending  to  the  arms  and  legs  (polio- 
enoephalo-myelitic  type).  In  2,  beginning  in  the  medulla,  it  assumed  the 
amyotrophic  lateral  sclerosis  type. 

The  occupation  of  the  patients  is  very  suggestive.  Iu  10  there  was  a 
history  of  excessive  work  with  the  arms,  the  patients  being  smiths,  iron 
workers,  bricklayers,  boilermakers,  horseshoers,  stonemasons,  tailors, 
barbers,  locksmiths.     In  :■  there  was  a  history  of  syphilis,  iii  1  of  lead,  in 

2  of  grippe  and  the  puerpeiium,  iu  1  of  infantile  spinal  paralysis. 


310 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


pains  in  the  shoulder  or  arm,  associated  with  some  feelings  of 
numbness  and  weariness.  Muscular  wasting  then  begins  to  appear, 
and  usually  in  one  hand.  The  adductor  longus  pollicis  is  very 
early  affected,  also  the  thenar  muscles  and  the  interossei.  The 
atrophy  spreads  from  muscle  to  muscle,  and  does  not  follow  the  dis- 
tribution of  nerves,  although  the  ulnar-nerve  supply  is  most  seri- 
ously disordered.  The  ball  of  the  thumb  becomes  flattened,  and  the 
patient  cannot  abduct  or  flex  it  well.  When  the  radial  interossei 
are  reached  the  forefinger  cannot  be  abducted,  and  this  is  often  an 
early  sign.     The  disease  gradually  extends  upward,  attacking  the 

flexors  and  extensors  of  the  fore- 
arm, then  the  upper  arm  and 
shoulder.  Meanwhile  the  hand 
has  become  thin  and  flattened, 
flexion  of  wrist  and  extension  of  fin- 
gers are  lost,  and  a  characteristic 
"  griffin-claw"  appearance  results. 
After  a  time  (three  to  nine  months) 
the  other  arm  begins  to  be  affected. 
Occasionally  there  is  a  temporary 
remission. 

In  a  few  cases  the  atrophy 
begins  first  in  the  shoulders  and 
arms,  attacking  the  deltoid,  biceps, 
and  triceps,  then  extending  down- 
ward to  the  hands.  This  consti- 
tutes the  "  upper-arm  type. " 

If,  as  is  usually  the  case,  the 
Hands  disease  continues  to  progress,  it 
passes  from  the  shoulder  girdle  to 
the  deep  muscles  of  the  back,  then  downward,  involving  succes- 
sively the  hip  and  thigh  muscles,  the  glutei,  the  crural  extensors 
and  abductors  being  oftenest  chosen.  The  leg  muscles  may  be 
finally  involved,  but  they  usually  escape.  The  disease  as  it  de- 
scends continues  its  progress  in  the  trunk,  involving  the  intercostals. 
It  slowly  ascends  the  neck  also,  and  finally  leads  to  paralysis  of 
the  diaphragm,  or  a  bulbar  palsy  may  set  in. 

It  will  be  seen  that  the  ordinary  course  of  the  disease  is  from 
the  lower-arm  muscle  groups  (ulnar  and  median)  up  to  the  shoulder 
group  (middle  cervical  nerves),  then  down  through  the  dorsal  and 
lumbar  nerves,  rarely  reaching  the  sacral  groups.  In  very  rare 
cases  it  begins  in  the  legs  and  ascends. 

Along  with  the  wasting  there  are  a  corresponding  weakness  and 


Fig.  142.— Showing  Wasting  op 
in  Muscular  Atrophy. 


MUSCULAR   ATROPHIES   AND    DYSTROPHIES.  311 

paralysis,  but  the  paralysis  is  the  result  of  the  atrophy  and  does  not 
precede  it.  Fibrillary  twitchings  of  the  muscles  occur;  the  idio- 
pathic muscular  contraction  caused  by  striking  it  a  blow  is  very 
marked ;  myoid  tumors  are  easily  brought  out.  In  some  cases  the 
muscles  are  flaccid  and  toneless,  and  the  deep  reflexes,  knee  jerk, 
and  arm  jerk  disappear  early  (atonic  atrophy),  but  in  other  cases 
the  rigidity  and  tonicity  of  the  muscles  are  increased,  the  knee  jerks 
exaggerated,  and  we  have  tonic  atrophy.  This  condition  may  be 
so  marked  as  to  make  it  resemble  a  special  clinical  type  of  progres- 
sive atrophy  known  as  amyotrophic  lateral  sclerosis. 

The  electrical  irritability  of  the  muscles  lessens  to  both  galvanic 
and  faradic  currents,  but  no  marked  qualitative  changes  occur  at 
first.  Eventually  we  may  get  partial  degeneration  reactions,  but 
these  occur  late  in  the  disease,  unless  this  runs  a  very  rapid  course, 
when  fairly  typical  degeneration  reactions  may  be  got.  A  peculiar 
contraction  of  the  upper  limbs  is  sometimes  produced  by  placing  the- 
negative  pole  of  the  galvanic  battery  over  the  fifth  cervical  vertebra, 
and  the  positive  in  the  triangle  just  below  the  lower  jaw  (diplegic 
contraction  of  Remak).  A  peculiar  palmar  spasm  is  described  by 
Voeter,  caused  by  suddenly  interrupting  a  faradic  or  galvanic  current 
passed  along  the  affected  arm. 

In  typical  cases  of  progressive  muscular  atrophy  there  is  no 
amesthesia;  and  when  such  symptoms  develop  the  presence  of  peri- 
pheral disease  or  of  syringo-myelia  or  spinal  tumor  must  be  sus- 
pected. The  patients  may  suffer  from  rheumatic-like  pains  and 
from  paresthesias. 

The  affected  parts  often  show  excessive  sweating  and  congestion 
and  evidence  of  vasomotor  disturbance.  This  may  involve  the  face 
on  one  or  both  sides ;  one  pupil  may  be  larger  than  the  other,  due  to 
irritation  of  the  cilio-spinal  centre.  The  iris  reflex,  however,  is 
preserved,  and  the  optic  nerve  is  never  involved. 

The  sexual  power  is  often  weakened,  but  the  sphincters  are  not 
attacked.  The  urine  shows  variations  iu  the  amount  of  urea.  There 
is  usually  an  increase  of  lime  salts. 

Complications. — The  most  common  complication  is  an  extension 
of  the  process  to  the  medulla,  causing  disturbance  of  speech  and 
swallowing.  Muscular  atrophy  complicates  locomotor  ataxia,  but 
is  rarely  complicated  by  it.  A  high  degree  of  spasm  and  rigidity 
of  the  legs,  particularly,  may  occur,  causing  the  condition  known 
as  amoy trophic  lateral  sclerosis. 

Course  a, i<l  Duration. — The  disease  usually  progresses  steadily 
until  it  has  reached  an  advanced  stage,  when  it  may  stop.  Remis- 
sions may  occur  earlier,  however,  and  even  some  improvement  take 


312  DISEASES   OF   THE   NERVOUS   SYSTEM. 

place;  the  disease  then  ordinarily  progresses  again.  It  lasts  from 
two  years  to  thirty  or  more,  but  on  the  average  not  over  ten  or 
twelve  years.  Death  usually  occurs  from  pulmonary  disease,  owing 
to  the  weakness  of  the  respiratory  muscles.  Sometimes  the  exten- 
sion to  the  medulla  and  involvement  of  the  muscles  of  deglutition 
and  of  the  larynx  are  the  cause  of  death. 

Patliologij. — The  primary  anatomical  change  is  a  degenerative 
atrophy  of  the  cells  of  the  central  parts  and  anterior  horns  of  the 
gray  matter  of  the  spinal  cord .  The  atrophy  gradually  extends  and 
involves  the  whole  anterior  horn.  It  also  extends  vertically,  first 
down,  then  up.  Along  with  this  atrophy  are  degenerative  changes 
in  the  lateral  columns ;  consecutive  to  this  there  is  atrophy  of  the 
anterior  roots,  peripheral  nerves,  and  the  muscles.  The  disease 
begins  in  the  deeper  parts  of  the  anterior  cornua,  involving  the 
central  and  median  groups  of  cells.  These  are  more  concerned  in 
nutrition  and  in  the  finer  muscular  movements  of  the  extremities. 
Hence  atrophy  always  precedes,  or  at  least  keeps  pace  with  paraly- 
sis. The  levels  affected  are  the  lower  cervical  and  upper  dorsal ; 
but  if  the  disease  is  extensive  the  dorsal,  lumbar,  and  sacral  cord 
are  also  involved.  The  affected  part  is  nearly  free  from  nerve  cells, 
and  those  present  are  atrophied,  their  processes  are  short  or  absent, 
and  the  cell  has  lost  its  angular  appearance.  Sclerotic  and  pigmen 
tary  changes  are  observed.  The  neuroglia  and  connective-tissue 
<;ells  are  increased  in  number,  but  there  are  no  marked  changes  in 
the  blood-vessels,  though  these  may  be  much  dilated.  There  is 
always  some  degeneration  of  the  lateral  columns,  and  this  may  be 
very  complete.  It  is  confined  chiefly  to  the  pyramidal  tracts, 
but  extends  somewhat  anteriorly  into  the  mixed  lateral  column. 
It  does  not  affect  the  cerebellar  or  ascending  lateral  tracts.  The 
•degeneration  has  been  traced  up  into  the  brain  as  far  as  the  in- 
ternal capsule  and  even  to  the  cortex.  The  anterior  columns 
may  be  slightly  affected.  The  posterior  horns,  columns,  and  roots 
are  normal. 

The  affected  muscles  show  various  degrees  of  degeneration. 
They  are  pale  and  streaked  with  yellow,  due  to  fatty  deposits. 
Some  fibres  may  be  simply  narrow  and  shrunken;  others  have  lost 
their  striation  and  become  granular  from  deposit  of  fat  globules  or 
degenerated  muscle  elements ;  other  fibres  have  lost  their  striations 
and  appear  as  if  filled  with  a  homogeneous,  glassy -looking  substance 
containing  a  few  fat  granules  (vitreous  degeneration) ;  others  show 
a  longitudinal  striation.  The  interstitial  connective  tissue  is  in- 
creased and  in  places  has  taken  the  place  entirely  of  the  muscles. 
The  capillaries  and  small  vessels  are  distended.     Healthy  fibres 


MUSCULAR   ATEOPHIES   AXD    DYSTROPHIES.  313 

may  be  seen  among  the  diseased.  Changes  have  been  found  in  the 
sympathetic  nervous  system,  but  they  are  unimportant. 

The  diagnosis  has  to  be  made  from  the  progressive  muscular 
dystrophies,  chronic  poliomyelitis  anterior,  syringomyelia,  neuritis, 
and  neuritic  family  atrophy. 

In  the  muscular  dystrophies  there  is  commonly  a  history  of 
heredity;  the  disease  begins  usually  in  childhood  or  adolescence. 
It  attacks  the  lower  limbs  of tener;  it  is  slower  in  progress;  there 
are  no  fibrillary  contractions,  and  the  degeneration  reaction  does 
not  occur. 

Chronic  poliomyelitis  anterior  begins  suddenly  and,  having 
reached  its  height,  does  not  progress,  but  remains  stationary  or  im- 
proves. The  paralysis  occurs  first,  the  wasting  follows.  It  affects 
groups  of  muscles  physiologically  related,  while  progressive  mus- 
cular atrophy  attacks  muscles  only  anatomically  related.  There  are 
cases,  however,  which  seem  to  be  on  the  border  line  between  the  two 
diseases. 

Syringomyelia  is  distinguished  by  the  presence  of  peculiar 
sensory  and  trophic  disorders. 

Neuritis  caused  by  lead  poisoning  is  detected  by  the  history  of 
the  case,  its  tendency  to  affect  the  extensors  of  the  arm  chiefly,  and 
the  absence  of  a  progressive  tendency.  Sometimes,  however,  lead 
poisoning  and  palsy  end  in  true  progessive  muscular  atrophy. 

Ordinary  multiple  neuritis  is  distinguished  easily  by  its  rapid 
onset  and  the  presence  of  painful  symptoms. 

The  hereditary  or  "  leg  type"  of  progressive  muscular  atrophy  is 
characterized  by  its  beginning  in  the  legs,  by  a  good  deal  of  sensory 
disturbance,  typical  degeneration  reactions,  and  hereditary  or  family 
history. 

Treatment. — The  patient  should  be  well  fed  and  have  rest,  quiet, 
and  fresh  air.  Careful  local  faradization  and  galvanization  of  the 
spine  and  neck  are  indicated.  Massage  does  no  good.  Hypodermic 
injections  of  strychnine  in  the  affected  member,  gr.  ^  to  ^  daily, 
the  internal  use  of  arsenic,  phosphorus,  iron,  quinine,  and  cod-liver 
oil  sometimes  are  beneficial. 

In  a  few  cases  with  a  syphilitic  history,  mercury  and  iodide  of 
potassium  have  proved  useful.  The  essentials  of  treatment  are  rest, 
electricity,  strychnine  locally,  the  administration  of  powerful  tonics, 
and  overfeeding.  Nitroglycerin,  morphine,  atropine,  nitrate  of 
silver,  chloride  of  gold  and  of  barium,  and  the  nitrate  of  uranium 
may  be  tried. 


314  diseases  of  the  nervous  system. 

Progressive  Hereditary  Muscular  Atrophy  of  Leg  Type 
(Charcot-Marie  Type). 

This  is  a  hereditary  or  family  muscular  atrophy  of  central  (or 
neuritic?)  origin,  beginning  in  the  legs  and  extending  upward.  It 
affects  males  more  than  females,  but  the  difference  is  not  great.  It 
almost  always  begins  before  the  age  of  twenty.  It  attacks  first  the 
muscles  of  the  leg,  not  the  foot,  involving  the  peronei,  then  the 
extensors  of  the  toes,  then  the  calf  muscles.  The  thighs  escape  till 
later.  After  some  years  the  upper  extremities  and  small  hand 
muscles  are  reached.  The  shoulder  and  arm,  neck  and  trunk  mus- 
cles escape.  There  are  occasionally  fibrillary  contractions;  and 
always  partial  or  complete  degenerative  electrical  reactions.  The 
patients  complain  of  some  pain  and  numbness,  but  there  is  no  anaes- 
thesia. 

The  disease  runs  a  long  course,  with  remissions,  and  resembles 
in  prognosis  the  dystrophies.  The  outlook  is  better  than  in  the 
arm  type,  but  the  disease  is  not  curable. 

Some  authorities  assert  that  the  disease  is  due  to  a  progressive 
degenerative  neuritis.  In  the  writer's  opinion  the  anterior  horns 
of  the  spinal  cord  are  primarily  attacked,*  a  view  recently  confirmed 
by  Marinesco. 

The  treatment  is  the  same  as  for  the  other  forms  of  hereditary 
muscular  atrophy. 

Glosso-Labio-Laryngeal  Paralysis  (Progressive  Bulbar 
Paralysis)  . 

This  is  a  disease  characterized  by  progressive  wasting  and  pa- 
ralysis of  the  muscles  of  the  tongue,  lips,  palate,  and  throat,  due  to 
an  atrophy  of  the  nuclei  of  the  nerves  supplying  those  parts. 

Etiology. — It  is  a  disease  of  the  degenerative  period  of  life,  most 
cases  occurring  after  forty  and  between  that  time  and  seventy. 
The  disease  begins  later  in  life  than  spinal  atrophy.  It  occurs 
rather  oftener  in  men  than  women. f  A  neurotic  heredity  is  some- 
times noted.  Exposure  to  cold  and  excessive  use  of  the  muscles  in 
talking,  mental  strain,  debilitating  influences,  lead,  and  syphilis  are 
causal  factors. 

*  The-writer  has  seen  the  disease  in  a  typical  form  in  one  member  of  the 
first  generation,  in  two  members  of  the  second.  A  child  of  one  of  the  latter 
had,  at  the  age  of  two  years,  a  typical  attack  of  anterior  poliomyelitis. 

f  While  this  is  the  usual  statement,  in  my  experience  women  suffer  much 
oftener  than  men. 


MUSCULAR    ATROPHIES   AND    DYSTROPHIES.  315 

Symptoms. — The  tongue  is  the  part  first  affected.  The  patient 
speaks  indistinctly  and  cannot  articulate  the  lingual  consonants  I, 
r,  ?i,  and  t.  The  tongue  cannot  be  elevated  and  is  protruded  only  a 
little  distance.  It  looks  scarred  and  wrinkled.  The  lips  become 
weak  and  the  patient  cannot  whistle  nor  make  the  consonants  %),  b, 
m,  or  the  vowel  o.  The  saliva  begins  to  dribble  from  the  mouth. 
Disturbance  in  swallowing  soon  develops.  Hard  solids  are  taken 
with  difficulty,  next  fluids,  while  semisolids  are  generally  managed 
best.  The  lips  finally  become  so  paralyzed  that  the  mouth  cannot 
be  shut,  and  the  lower  part  of  the  face  is  motionless  and  expression- 
less. The  upper  face  wears  an  expression  of  anxiety  and  suffering, 
the  saliva  dribbles  constantly,  and  the  whole  physiognomy  of  the 
patient  becomes  characteristic  and  pitiful  in  the  extreme.  The 
facial  nerve  may  get  somewhat  involved.  Articulation  becomes 
almost  entirely  lost;  the  voice  has  a  nasal  twang  from  paralysis  of 
the  palate. 

The  patient  has  tired  and  uncomfortable  sensations  of  dryness 
and  stiffness  about  the  throat.  There  is  no  pain  or  anaesthesia, 
but  occasionally  there  is  impairment  of  the  sense  of  taste.  The 
throat  reflex  is  usually  lost,  so  that  tickling  it  causes  no  reaction. 

Electric  irritability  is  at  first  unchanged,  but  in  the  later  stages 
partial  degeneration  reaction  occurs.  In  rare  cases  there  is  a  rapid 
pulse  and  still  more  rarely  glycosuria. 

The  laryngeal  reflex  becomes  weak,  the  adductors  also,  but 
abductor  paralysis  is  rare. 

The  mind  is  not  affected,  but  there  are  often  an  emotional  weak- 
ness and  tendency  to  tears — not  entirely  unreasonable  in  view  of 
the  distressing  nature  of  the  malady. 

The  disease  is  often  the  terminal  stage  of  spinal  muscular 
atrophy;  it  may  be  associated  with  the  latter,  with  amyotrophic 
lateral  sclerosis,  or  with  ophthalmoplegia.  All  these  types  may 
occur  together. 

It  runs  a  progressive  course,  with  remissions  of  a  few  weeks  or 
months.  It  lasts  from  one  to  three  or  four  years.  In  one  case  it 
has  lasted  seven  years. 

The  termination  is  eventually  fatal.  Death  occurs  through  in- 
terference with  swallowing,  and  inanition  or  a  broncho-pneumonia 
or  bronchitis  may  develop  which  ends  the  patient's  life. 

Pathology. — The  primary  lesion  is  found  in  the  nuclei  of  origin 
of  the  hypoglossal,  glosso-pharyngeal,  vagus,  and  spinal  accessory 
nerves.  The  raphe  fibres  and  the  anterior  pyramids  are  also  usually 
somewhat  involved.  There  is  sometimes  atrophy  of  the  cells  of  the 
facial  nerve  and  of  the  nucleus  ambiguus,  which  is  the  motor  nucleus 


316  DISEASES    OF   THE   NERVOUS   SYSTEM. 

of  the  vagus.  The  brunt  of  the  disease  falls,  therefore,  upon  those 
more  superficial  or  posterior  nuclei  which  are  representative  of  a 
continuation  of  the  anterior  cornual  cells.  If  the  disease  is  compli- 
cated with  amyotrophic  lateral  sclerosis,  or  progressive  muscular 
atrophy,  or  ophthalmoplegia,  we  find  atrophy  in  the  cord  or  ocular 
nuclei.  The  atrophic  process  is  similar  to  that  observed  in  the 
spinal  disease. 

The  muscles  of  the  tongue,  and  to  a  less  extent  the  orbicularis 
oris  and  the  throat  muscles,  show  evidences  of  degeneration  and 
atrophy.  In  some  cases  the  tongue  is  not  shrivelled,  owing  to  the 
presence  of  a  fatty  deposit,  and  on  account  of  this  the  disease  has 
been  divided  into  atrophic  and  paralytic  types,  but  this  distinction 
is  unnecessary. 

Diagnosis. — The  disease  must  be  distinguished  from  polio-ence- 
phalitis inferior,,  bulbar  apoplexy,  tumors,  and  softening,  from  mul- 
tiple sclerosis,  and  from  chronic  lesions  of  the  cerebral  hemispheres 
causing  pseudobulbar  paralysis.  It  must  also  be  distinguished 
from  asthenic  bulbar  palsy.  The  slow  onset,  the  progressive  course, 
the  bilateral  character,  the  absence  of  involvement  of  sensory  nerves, 
and  the  degenerative  reactions  are  sufficient  for  a  diagnosis.  In 
asthenic  bulbar  palsy  there  is  great  paralysis,  but  none  of  the 
typical  atrophy  of  the  parts.  It  is  important  always  to  note 
whether  there  are  ophthalmoplegia  and  spinal  muscular  atrophy 
associated  with  the  disease. 

Treatment. — The  patient  should  be  kept  quiet;  he  must  be  over- 
fed and  given  massage  and  electricity  in  moderation.  The  same 
drug  treatment  as  in  the  spinal  disease  is  indicated.  Small  doses  of 
morphine,  gr.  -^  to  -Jg-,  and  of  atropine  may  be  given  also.  Elec- 
tricity should  be  tried  for  a  short  time  twice  or  even  thrice  daily,  if 
possible.  The  faradic  current  may  be  used,  alternating  or  combined 
with  the  galvanic.  Galvanization  of  the  neck  and  medulla  appears 
to  do  no  good.  After  a  time  it  may  be  necessary  to  feed  with  a 
tube  or  even  to  do  tracheotomy. 

Asthenic  Bulbar  Paralysis  and  Asthenic  Bulbo-Spinal 

Paralysis. 

These  names  are  given  to  a  chronic  and  progressive  disorder 
characterized  by  the  symptoms  of  progressive  bulbar  paralysis  or  by 
the  symptoms  of  this  disease  and  of  progressive  muscular  atro- 
phy, the  distinguishing  features  being  that  there  is  no  muscular 
atrophy,  that  the  cases  often  continue  on  for  many  years  instead  of 
going  on  progressively  to  a  fatal  issue,  and  also  by  the  fact  that 
on  autopsy  no  easily  distinguishable  microscopical  changes  are  found. 


MUSCULAR   ATROPHIES   AND    DYSTROPHIES.  317 

Etiology. — Little  is  known  as  to  the  cause  of  the  disease.  The 
majority  of  cases  have  been  under  the  age  of  thirty,  but  a  patient 
of  my  own  was  over  fifty  years  of  age  and  another  over  forty.  It 
is  sometimes  associated  with  profound  anaemia.  Those  causes  which 
are  found  in  progressive  bulbar  and  spinal  paralysis,  viz.,  overwork, 
mental  strain,  are  sometimes  found  here. 

Symptoms. — The  disease  usually  begins  gradually  and  oftenest 
affects  the  muscles  of  the  throat  and  face  and  of  the  eyes.  A  fre- 
quent symptom  is  ptosis  of  either  one  or  both  eyes.  This  may  be 
followed  by  weakness  or  paresis  of  the  muscles  of  mastication,  de- 
fect in  articulation,  and  difficulty  in  swallowing.  The  voice 
becomes  nasal  and  the  appearance  of  the  patient  very  much  re- 
sembles that  of  a  case  of  glosso-labio-laryngeal  paralysis.  At  the 
same  time,  with  some  ophthalmoplegia,  there  develop  feelings  of 
great  exhaustion  and  extreme  weakness  in  the  arms  and  legs.  The 
patient  becomes  incapable  of  anything  but  the  slightest  exertion 
and  at  times  he  is  unable  either  to  raise  the  arms  or  to  stand  upon 
the  feet.  The  symptoms  are  characterized  by  remissions ;  after  a  pa- 
tient has  reached  a  point  at  which  he  is  almost  moribund,  he  begins 
to  get  stronger  again  and  may  slowly  get  into  a  state  of  comparative 
strength;  then  the  symptoms  slowly  return.  In  this  way  the  dis- 
ease may  continue  for  a  number  of  years.  The  patient  usually  dies 
of  exhaustion,  but  he  sometimes  recovers. 

Pathological  Anatomy. — In  the  half-dozen  careful  autopsies  so 
far  made,  no  lesion  of  the  nervous  system  has  been  found,  except 
microscopical  changes  in  the  cells  of  the  motor  nuclei. 

Diagnosis.  —The  clinical  characteristic  which  distinguishes  this 
disease  from  progressive  muscular  atrophy  and  true  bulbar  palsy  is 
the  fact  that  there  is  no  true  atrophy  of  the  muscles  of  the  face  or 
tongue  or  extremities,  there  are  no  fibrillary  twitchings,  and  the 
course  is  irregular  with  remissions.  Like  these  other  diseases, 
however,  asthenic  paralysis  is  not  accompanied  by  any  disturb- 
ance of  sensibility  or  any  impairment  of  the  uphincters.  The 
patient  may  die  in  six  months,  or  he  may  live  for  six  years,  or  even 
recover. 

The  treatment  consists  in  complete  rest,  careful  attention  to 
feeding,  and  the  use  of  iron  and  arsenic,  and,  possibly,  of  quinine. 
Strychnine  and  muscular  stimulants  should  be  given  with  great  care. 
Faradism  is  not  advisable,  but  the  use  of  a  stable  galvanic  current  is 
reported  to  have  done  good. 


318  DISEASES   OF   THE   NERVOUS   SYSTEM. 

Amyotrophic  Lateral  Sclerosis. 
(Spastic  Form  of  Progressive  Muscular  Atrophy.) 

This  disease  is  one  which  has  the  closest  possible  kinship  to  pro- 
gressive muscular  atrophy  which  we  have  just  described.  There 
has  been  an  enormous  amount  of  discussion  as  to  whether  a  distinct 
place  should  be  given  to  the  disorder.  The  question  is  a  very 
academic  one,  for  in  everything  that  really  constitutes  a  special 
malady  it  is  essentially  the  same.  However,  its  clinical  symptoms 
are  somewhat  different,  and  anatomically  there  is  a  somewhat  more 
extensive  and  peculiar  change. 

Amyotrophic  lateral  sclerosis,  or  Charcot's  disease,  is  character- 
ized by  progressive  paralysis  with  atrophy,  rigidity,  and  contractures 
of  the  limbs. 

Etiology. — It  is  a  rarer  disease  than  progressive  muscular 
atrophy,  and  occurs  most  often  between  the  ages  of  thirty-five  and 
fifty,  involving  the  second  part  of  adult  life.  Rare  cases,  however, 
have  been  reported  as  occurring  in  childhood.  According  to  Marie, 
the  female  sex  is  rather  more  often  affected.  According  to  the  same 
author,  no  definite  exciting  cause  is  known.  It  is  not  due  to  syphi- 
lis or  lead  poisoning,  nor  does  it  follow  the  acute  infectious  dis- 
eases. It  is  therefore  considered  a  disease  of  involution,  i.e.,  tera- 
tological  defect,  the  first  and  second  motor  neurons  degenerating 
because  of  inherently  deficient  vitality.  This  state  of  affairs,  how- 
ever, underlies  the  other  atrophies  also. 

Symptoms. — The  disease  begins  most  often  with  symptoms  refer- 
able to  the  medulla,  but  it  may  affect  first  the  arms,  and  less  often 
the  legs.  The  patient  first  notices  some  difficulty  in  speaking  or 
swallowing.  He  feels  at  times  a  spasmodic  drawing  of  the  tongue 
or  stiffness  of  the  cheek  or  lips.  Soon  after  there  appear  a  weakness 
and  stiffness  of  the  legs  and  arms.  The  symptoms  progress  rather 
slowly.  The  speech  becomes  disturbed ;  swallowing  is  difficult ;  the 
arms  atrophy  and  become  stiff  and  rigid,  producing  characteristic 
deformities.  There  is  great  exaggeration  of  the  reflexes;  the  legs 
show  the  presence  of  ankle  clonus ;  all  the  arm  reflexes  are  increased, 
and  the  jaw  is  stiff  and  has  a  very  lively  jerk  when  struck.  The 
patient  suffers  little  from  pain.  There  are  no  anaesthesia  and  no 
sphincter  trouble,  except  in  the  last  stages  of  the  disease.  In  the 
course  of  a  year  the  patient  may  become  quite  bedridden,  with 
rigidity  and  deforming  contractures  of  both  arms  and  legs.  In 
other  cases  the  atrophies  and  contractures  of  the  arms  are  not  so 
marked,  and  the  disease  shows  itself  mainly  in  bulbar  symptoms, 
progressing  very  much  like  a  case  of  glosso-labio-laryngeal  paraly- 


MUSCULAR    ATROPHIES    AXD    DYSTROPHIES.  310 

sis,  plus  a  certain  amount  of  rigidity  and  excessive  reflex  irritability 
of  the  throat  and  jaws.  The  course  of  the  disease  is  variable  but 
usually  not  long.  When  it  begins  and  is  most  marked  in  the 
medulla,  the  duration  is  shortest.  It  rarely  lasts,  in  any  case, 
more  than  two  or  three  years. 

Pathological  Anatomy. — Post-mortem  examinations  show  a  very 
marked  sclerosis  involving  the  direct  and  crossed  pyramidal  tracts ; 
also  some  of  the  short-fibre  systems  of  the  lateral  column.  The 
anterior  cornual  cells  are  atrophied,  as  in  progressive  muscular 
atrophy.  Lesions  are  also  seen  at  times  in  the  columns  of  Goll. 
In  fact,  the  post-mortem  findings  resemble  entirely  those  of  pro- 
gressive muscular  atrophy,  except  that  there  is  a  sharper  accen- 
tuation of  the  disease  in  the  lateral  tracts.  In  the  medulla  the 
nuclei  of  the  hypoglossal  and  other  motor  cranial  nerves  will  be 
found  diseased  and  the  pyramidal  tracts  also.  The  lesion  of  the 
white  columns  diminishes  in  intensity  from  below  up,  so  that  as  one 
gets  into  the  cerebral  peduncles  very  little  if  any  is  to  be  seen.  In  a 
few  cases,  however,  the  process  has  been  traced  to  the  motor  cor- 
tex and  changes  even  in  that  part  have  been  discovered.  In  a  case 
of  my  own,  which  was  very  closely  studied  and  reported  upon  by 
Dr.  Jos.  Collins,  the  sclerosis  of  the  movor  tracts  did  not  reach 
above  the  medulla,  and  there  was  no  lesion  of  any  moment  in  the 
cortical  motor  cells. 

]JntJu)b»jij. — In  amyotrophic  lateral  sclerosis  the  degenerative 
process  attacks  first  the  terminal  fibres  and  collaterals  of  the  cor- 
tical motor  neurons.  It  seems  to  destroy  the  tips  of  the  nerve  proc- 
.  so  to  speak,  without  involving  the  nerve-cell  body  itself. 
The  next  part  attacked  is  the  anterior  cornual  cell.  We  have  there- 
fore the  curious  and  perplexing  phenomenon  of  a  disease  which 
attacks  the  cell  body  of  one  neuron  and  the  terminal  neuraxon  of 
another  neuron  just  above  it.  It  is  difficult  to  explain  this  upon  the 
ordinary  lines  of  nerve-cell  pathology.  Still,  we  have  analogies, 
perhaps,  both  in  locomotor  ataxia  and  in  multiple  neuritis. 

The  diagnosis  of  amyotrophic  lateral  sclerosis  must  be  made  from 
transverse  myelitis,  multiple  sclerosis,  and  the  other  forms  of  pro- 
gressive muscular  atrophy.  The  diagnosis  is  based  upon  the  very 
striking  and  progressive  atrophy  associated  with  exaggerated  re- 
,  rigidity,  and  contractures,  and  without  any  sensory  Bymptoma 
oi-  sphincter  troubles.  The  diagnosis  from  ordinary  bulbar  palsy 
depends  upon  the  appearance  of  silliness,  cramps,  exaggerated 
reflexes,  and  rigidity  displayed  by  the  muscular  supply  of  the  facial, 
the  trigeminal,  and  the  glossopharyngeal,  and  the  tenth,  eleventh 
and  twelfth  cranial  nerves. 


320 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


The  prognosis  is  invariably  bad,  but  in  those  types  beginning  in 
the  legs  and.  arms  life  may  be  prolonged  a  number  of  years. 

The  treatment  is  the  same  as  that  for  progressive  muscular 
atrophy. 

THE  PROGRESSIVE   MUSCULAR  DYSTROPHIES. 

As  I  have  already  stated,  there  are  various  forms  of  progressive 
muscular  atrophy  to  which  the  special  name  of  "  dystrophy"    is 


A.  B. 

Fig.  143.— Showing  the  Parts  First  Attacked  in  the  Different  Types  of  Muscu- 
lar Dystrophy  and  Muscular  Atrophy.  The  shaded  parts  in  A  show  the  place  of  onset 
of  progressive  muscular  atrophy  of  ordinary  or  Duchenne-Aran  type,  of  leg  type,  and  of 
types  2  and  3  in  text.     B  shows  place  of  onset  of  types  1  and  (a)  in  text. 

given,  because  they  are  hereditary  in  character  and  because  the  mus- 
cular end  of  the  motor  neuron  is  apparently  the  first  and  the  most 
severely  attacked.  Kecent  and  closer  study  of  the  pathology  of 
muscular  dystrophy  tends  to  show  that  the  lesion  is  not  in  the 
muscle  and  terminal  of  the  motor  nerves  alone,  but  that  the  pe- 
ripheral motor  neuron  is  also  to  some  extent  affected.  The  clinical 
characteristics  of  the  muscular  dystrophies,  however,  are  pretty 
distinct  and  are  sufficient  to  justify  the  separation  of  them  into  a 
different  class. 


MUSCULAR    ATROPHIES    AND    DYSTROPHIES. 


321 


A  number  of  types  has  been  described,  the  distinctions  being 
based  chiefly  on  the  part  of  the  body  first  affected.  These  types 
are  not  of  great  importance,  but  may  be  enumerated  here  for  con- 
venience  (Fig.  143) : 

1.   Pseudo-muscular  hypertrophy. 

cm  Leyden-Mobius  or  hereditary  type,  appearing  in  children, 
beginning  in  the  back  and  lower  limbs. 

1'.  Erb's  juvenile  type,  or  seapulo-huineral  type,  beginning  in 
childhood  or  youth,  usually  in  the  shoulder  girdle  or  trunk. 

3.  Landouzy-Dejerine  type,  or  infantile  progressive  muscular 
atrophy  of  Duchenne,  or  facio-scapulo-humeral  type.  It  resembles 
the  preceding  form,  with  the  exception  that  it  involves  the  face. 

4.  The  peroneal  or  leg  type  has  been  classed  with  the  dystro- 
phies, but  is  probably  of  spinal  or  neuritic  origin,  and  has  been 
described  Avith  the  atrophies  (see  page  314). 

The  essential  unity  of  all  these  different  forms  is  shown  by  the 
fact  that  cases  occur  in  which  pseudohypertrophy  takes  place  in 
the  scapulo-humeral  and  other  types,  by  the  fact  that  a  disease  re- 
sembling pseudohypertrophic  paralysis  occurs  without  any  hyper- 
trophy, and  by  the  fact  that  different  types  occur  in  the  same 
family.  The  unity  of  the  spinal  and  muscular  forms  is  shown  by 
the  same  kind  of  clinical  evi- 
dence. 

At  the  same  time  the  classical 
types  of  dystrophies  art-  very  dif- 
ferent clinically  from  the  spinal 
amyotrophies  and  hence  must  be 
separately  described.  The  differ- 
ences will  be  shown  under  the  head  of 
diagnosis. 

Pseudo-M  [jscui-ar    Hypertrophy    (  Atro- 
phia Musculorum  Lipomatosa). 

This  is  a  disease  beginning  in  child- 
hood and  characterized  by  a  progressive 
weakness  of  the  legs,  associated  with  an 
apparent  muscular  hypertrophy  due  to  a 
deposit  of  fat  in  the  wasting  muscles. 

Etiology. — The  disease  attacks  boys 
much  oftener  than  girls.  It  begins,  in  1 1n- 
vast  majoritv  of  eases,  under  the  age  of 
.  «,  ,11  c    ■    £  FlQ-  '"•  -PsmJDO- 

ten,    otten    at    the   close   ot    infancy,    very         hypertrophy 

21 


322 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


rarely  not  till  after  puberty.  Heredity  is  a  very  important  factoi 
(in  three-fifths  of  the  cases),  the  hereditary  influence  being  al- 
most always  transmitted  by  the  mother.  A  psychopathic  or  neu- 
ropathic condition  is  often  found  in  the  ancestry.  Xeuroses, 
syphilis,  intemperance,  consanguinity,  are  not  factors  in  heredi- 
tary causation.  Injury  and  an  acute  disease  sometimes  appear  to 
act  as  exciting  causes. 

Symptoms. — The  first  symptom  noticed  is  a  weakness  in  the 
legs,  which  shows  itself  in  a  peculiar  "  waddling  gait"  and  a  ten- 
dency to  stumble  and  fall.  A  little  later  (fifth  or  sixth  year)  an 
apparent  hypertrophy  of  the  leg  muscles,  particularly  of  those  of  the 

calves,  develops.     The  ex- 

of  them  and  the  gluteal  and 
lumbar  muscles  may  also  be 
affected.  Sometimes  the 
hypertrophy  is  very  great, 
at  other  times  it  is  barely 
noticeable.  The  affected 
part  has  a  peculiar,  hard, 
non-elastic  feeling  to  the 
hand,  not  like  that  of  nor- 
mal muscle.  In  the  up- 
per part  of  the  body  the 
hypertrophy  oftenest  at- 
tacks the  infraspinatus. 
The  supraspinatus  and  del- 
toid may  be  somewhat  in- 
volved (Fig.  145).  The 
lower  parts  of  the  pecto- 
ralis  major  and  latissimus 
dorsi  are  also  usually 
atrophied,  giving  a  charac- 
teristic appearance  to  the 
shoulders.  The  upper- 
arm  muscles  are  often 
slightly  wasted,  the  fore- 
arm, neck,  and  face 
rarely.  The  tongue  may 
be  hypertrophied. 
Along  with  the  pseudohypertrophy  there  occurs  an  atrophy  of 
certain  groups  of  muscles;  and  after  a  time  the  pseudohypertrophy 
disappears  and  an  atrophy  takes  its  place.     In  the  lower  limbs  the 


Fig.   145.—  Pseudo-Muscular    Hypertrophy,    in- 
volving legs  and  shoulders  (Curshmann). 


MUSCULAR  ATROPHIES  AST)    DYSTROPHIES.         323 

muscles  most  atrophied  are  the  flexors  of  the  hips,  then  the  exten- 
sors of  the  knee  and  those  of  the  hip.  The  calf  muscles  fail  before 
the  anterior  tibial.  The  atrophy  and  consequent  weakness  of  the 
lower-limb  muscles  cause  great  difficulty  in  going  upstairs,  the  gait 
becomes  more  waddling,  and  the  patient  loses  the  power  of  getting 
up  when  lying  on  the  floor.  These  peculiarities  are  due  chiefly 
to  the  weakness  in  the  extensors  of  the  knees,  the  extensors  of 
the  hip,  and  the  flexors  of  the  hip.  By  reason  of  the  same  de- 
fects, the  child  when  standing  has  an  antero-posterior  curvature  of 
the  spine  with  the  concavity  backward  (lordosis)  (Fig.  144).  This 
is  due  to  the  weakness  of  the  extensors  of  the  hips,  which,  acting 
from  the  hips,  are  unable  to  tilt  the  pelvis  back.  On  sitting  this 
lordosis  disappears,  and  is  replaced  often  by  a  curve  in  the  opposite 
direction  due  to  weakness  of  the  erectors  of  the  spine.  There  may 
be  some  lateral  curvature  also.  In  consequence  of  the  weakness  and 
contractures  of  the  leg  muscles,  there  early  develops  a  talipes 
equinus,  and  later  the  legs  may  become  flexed  on  the  hips  and  the 
forearms  on  the  arms. 

The  muscles  show  no  fibrillary  twitchings  and  rarely  any  degen- 
erative reactions,  but  there  is  sometimes  a  peculiar  tetanic  contrac- 
tion with  both  the  faradic  and  the  galvanic  current. 

The  knee  jerks  and  elbow  jerks  gradually  weaken  and  in  time 
are  lost. 

There  is  no  pain  or  other  disturbance  of  sensibility. 

The  affected  parts  feel  cold  and  look  reddened,  as  if  from  deficient 
vasomotor  innervation.  The  organic  spinal  centres  are  not  involved. 
Intelligence  is  usually  good. 

('nurse. — The  disease  runs  a  chronic  but  variable  course.  Its 
progress  is  at  first  slow ;  after  walking  becomes  impossible  it  may 
cease  to  progress.  It  lasts  from  ten  to  twenty-five  years.  In  a  few 
cases  patients  have  reached  the  age  of  fifty  or  sixty  years,  even 
when  the  disease  began  in  youth.  The  earlier  the  disease  begins 
the  more  rapidly  it  extends;  the  more  pronounced  the  tendency  to 
lipomatosis,  the  more  rapid  is  the  course. 

"Pathological  Anatomy. — The  disease,  like  other  forms  of  dys- 
trophy, is  a  degenerative  atrophy,  the  process  affecting  first  the 
muscle  fibres  and  nerve  terminals  and  the  connective  tissue  being 
secondarily  involved.  In  a  simple  atrophy  of  muscle,  such  as  fol- 
lows disuse,  the  muscle  fibres  simply  grow  smaller  and  gradually 
break  up  and  disappear.  In  degenerative  atrophy,  the  process  is 
accompanied  by  evidences  of  irritation,  such  as  swelling  of  the 
muscle  fibre,  proliferation  of  muscle  nuclei,  splitting  of  the  fibre 
longitudinally,  and  connective-tissue  proliferation.     All  these  phe- 


324 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


nomena  are  seen  in  the  pathological  process  which  takes  place  in 
the  dystrophic  muscles.  All  the  varied  changes  may  be  noted  in 
the  same  muscle.  In  the  early  stages  there  is  a  true  hypertrophy 
of  some  of  the  fibres,  a  condition  thought  to  be  characteristic  of 
the  muscular  dystrophies  in  distinction  from  the  spinal  atrophies. 
Besides  swelling  and  hypertrophy  of  fibres,  one  sees  atrophy  of  the 
fibres ;  the  bundles  are  rounded ;  there  are  increase  of  niuscle  nuclei, 


Fig.  14G.  —Partially  Diagrammatic,  showing:  A,  hypertrophied  fibres ;  2?,  mixture  of 
hypertrophy  and  atrophy;  C,  D,  atrophy  and  fatty  deposit;  v,  vacuolization;  s,  splitting; 
fc,  hypertrophy  of  fibres;   g,  thickened  blood-vessel  (Erb). 


splitting  of  fibres,  vacuolization,  and  a  tendency  to  break  up  into 
fibrilke  (Erb).  The  connective  tissue  at  first  shows  evidence  of 
irritation  and  "proliferation.  Finally,  as  the  muscular  atrophy  pro- 
gresses, connective  tissue  increases  and  takes  its  place,  until  a 
dense,  hard  myosclerosis  results  (Fig.  146).  In  some  parts  there 
is  deposit  of  fat  in  the  connective-tissue  cells,  and  this  may  in- 
crease until  an  extensive  lipomatosis  exists.  In  the  later  stage  of 
the  disease  the  fat  deposits  are  absorbed  and  there  are  only  atrophied 
muscle  and  connective  tissue.  The  nerves  and  spinal  cord  are  usu- 
ally normal;  when  changes  are  found  they  are  secondary  to  the 
muscular  disease. 

The   process    is  then,    first,    hypertrophy    of  muscle   fibre  and 


MUSCULAR  ATROPHIES  AND  DYSTKOPHIES. 


325 


increase  of  muscle  nuclei,  swelling  and  rounding  of  fibres,  and 
splitting  of  the  same;  then  increase  of  connective  tissue,  with 
corresponding  atrophy  of  muscle  and  deposit  of  fat. 

The  process  is  a  primary  degeneration  due  to  an  inherent  nutri- 
tional weakness  of  the  muscle. 
In  a  measure  it  is  true  that 
those  muscles  embryologically 
latest  developed  are  earliest 
attacked. 

The    JUVENILE     DYSTROPHY 

of  EBB,  or  scapulo  -  humeral 
form  of  dystrophy,  begins  in 
childhood  or  early  youth,  a  lit- 
tle later  than  pseudohypertro- 
phy. The  shoulder  girdle  is 
first  affected,  later  the  arm. 
The  forearm  and  legs  are  at- 
tacked very  late.  Part  of  the 
pectorals,  part  of  the  trapezii, 
latissimus  dorsi,  r  h  o  m  b  o  i  d, 
upper-arm  muscles,  and  supi- 
nators are  affected,  while  the 
supra-  and  infraspinati  and 
forearm  and  hand  usually  es- 
cape. There  may  be  true  and 
false  muscular  hypertrophy. 
There  are  no  fibrillary  contrac- 
tions or  degenerative  reactions 
(Fig.  147). 

The  FACIO  -  SCAPULO  -  iiu- 
MEEAX  FORM,  or  infantile  pro- 
gressive muscular  atrophy, 
begins  ill  early  childhood  (third 
or  fourth  year)  usually,  but 
may  develop  late.  The  atro- 
phy attacks  first  the  face,  giv- 
ing a  characteristic  appear- 
ance known  as  the  "myopathic 
face."  There  is  a  weakness  of 
the  oral  muscle,  which  causes 
the  lips  to  protrude  and  produces  a  symptom  called  the  "tapir 
mouth."  The  atrophy  respects  the  eye  muscles  as  well  as  those 
of    mastication    and    deglutition.     It    extends    to    the    shoulder-, 


Fig.  147.—  Juvenile  Type  op  Progressive 
Mi'mi'ur  Dybtbopbtv;  sixth  year  of  dis- 
ease. 


320  DISEASES   OF   THE    NERVOUS    SYSTEM. 

and  arms  next,  then  it  pursues  the  ordinary  course  of  the  dys- 
trophies. 

Prognosis. — The  patient  never  recovers,  but  the  disease  some- 
times comes  to  a  standstill  and  there  may  even  be  some  improve- 
ment, especially  in  cases  beginning  late. 

Treatment. — The  prophylaxis  is  important.  It  consists  in  pre- 
venting the  marriage  of  women  belonging  to  dystrophic  families; 
if  a  dystrophy  has  developed  in  one  child,  it  would  be  unwise  to 
take  the  risk  of  bringing  others  into  the  world.  Or  if  children  are 
already  born,  they  should  receive  the  most  careful  nourishment, 
outdoor  life  should  be  secured,  and  the  dangers  from  trauma  and 
the  infective  diseases  be  prevented.  Infants  should  not  be  suckled 
by  the  mother  if  she  belongs  to  the  dystrophic  family. 

The  moderate  use  of  massage  and  gymnastics  is  very  important 
and  useful.  All  kinds  of  tonic  measures  are  indicated,  such  as 
cold  baths,  good  nourishment,  arsenic,  strychnine,  and  phosphorus 
and  fats.  Tenotomy  and  other  orthopaedic  measures  may  be  useful 
in  the  later  stages.     Feeding  with  thymus  gland  may  be  tried. 

Summary  of    the    Hereditary  or  Family  Nervous  Diseases. 

The  student  may  well  be  confused  by  the  large  number  of  so- 
called  family  nervous  diseases  which  modern  neurology  has  dis- 
covered and  differentiated.  The  practical  importance  of  them  all 
is,  perhaps,  slight,  for  they  are  extremely  rare,  yet  it  is  necessary 
that  they  be  recognized  and  properly  distinguished,  for  the  prognosis 
and  degree  of  suffering  differ  very  much  in  different  cases.  They 
are  all  characterized  by  the  fact  that  they  are  found  in  different 
generations  and  in  different  collateral  branches  of  a  given  family, 
and  that  they  are  not  necessarily  or  often  passed  on  directly  from 
one  parent  to  another.  The  list  which  I  append  may  not  be  en- 
tirely complete  at  the  time  of  publication  of  this  book,  but  it  is 
ample. 

Hereditary  Chorea. — This  is  really  a  kind  of  hereditary  paresis 
or  brain  softening.  It  does  not  develop  until  adult  life,  as  a  rule, 
and  patients  with  it  may  live  until  middle  age. 

Hereditary  amaurotic  idiocy  is  a  family  disease  first  described 
by  Dr.  Sachs,  characterized  by  lack  of  development  of  the  brain  and 
associated  with  blindness  and  a  peculiar  degeneration  of  the  optic 
nerves. 

Hereditary  Cerebral  Diplegia. — This  is  a  family  disease  in 
which  children  between  the  ages  of  one  and  five  develop  spastic 
paralysis  and  sometimes  imbecility. 

Hereditary  Hemiplegia. — This  is  a  family  disease  which  has 
been  referred  to  by  Hoffmann  and  of  which  I  have  seen  two  cases  in 
my  clinic.     The  children  are  born  hemiplegic  and  there  is  atrophy 


MUSCULAR    ATROPHIES   AND    DYSTROPHIES.  327 

of  the  hemiplegia  side,  but  in  my  cases  there  was  no  mental  defect 
or  epilepsy. 

Hereditary  cerebellar  ataxia  is  a  disease  allied  to  Friedreich's 
ataxia,  but  developing  somewhat  later,  i.e.,  about  the  time  of 
puberty. 

Hereditary  spinal  ataxia,  or  Friedreich's  disease,  is  fully  de- 
scribed elsewhere. 

Hereditary  ataxic  paraplegia  is  a  disease  developing  at  about 
the  same  time  and  with  some  of  the  same  symptoms  as  cerebellar 
ataxia. 

Hereditary  spastic  spinal  paralysis  is  a  disease  which  as  far  as  is 
known  develops  before  the  fifth  or  sixth  year  of  life,  involves  only 
the  lower  extremities,  and  is  compatible  somewhat  with  a  long  life. 
It  resembles  ataxic  paraplegia. 

Hereditary  progressive  spinal  muscular  atrophy  is  a  family  dis- 
ease, developing  in  the  first  year  of  life,  affecting  first  the  legs, 
and  gradually  ascending  and  running  a  rapid  course,  the  patient 
dying  in  three  or  four  years  (Hoffmann). 

The  hereditary  progressive  dystrophies  include  a  large  number 
of  progressive  diseases  affecting  primarily  the  muscles  and  the  mus- 
cular ends  of  the  peripheral  motor  neurons.  Many  different  types 
of  this  disease  are  described  in  accordance  with  the  muscles  which, 
are  first  attacked. 

Arthritic  Muscular  Atrophy. 

In  inflammation  of  joints  the  muscles  moving  them  are  affected 
by  a  simple  atrophy  which  is  called  arthritic. 

Etiology. — Rheumatic  arthritis  is  the  commonest  cause. 

Symptoms. — The  shoulder-girdle  muscles  are  oftenest  affected. 
Whatever  the  joint,  it  is  the  extensor  muscles  which  are  first  and 
most  attacked;  the  muscles  above  the  joint  are  more  susceptible  to 
the  atrophy  than  those  below.  The  atrophy  is  rather  rapid  in  the 
first  few  weeks  and  then  becomes  slower.  The  muscles  affected 
waste  throughout  their  whole  length.  They  show  no  fibrillary  con- 
traction and  no  degenerative  electrical  reaction.  There  is  often  an 
increased  irritability,  so  that  an  exaggerated  tendon  reflex  or  even 
clonus  may  be  produced.  There  is  no  pain  or  tenderness  or  anaes- 
thesia in  the  muscles. 

Pathology. — The  anatomical  change  is  a  simple  atrophy  and 
shrinking  of  the  muscle  fibres,  with  some  increase  in  muscle  nuclei, 
little  vacuolation,  no  swelling  or  splitting  of  fibres  (Darkschewitch 
— Fig.  148).  There  is  some  increase  in  interstitial  tissue,  but  this 
is  slight.     The  nerves  and  spinal  cord  are  normal. 

The  atrophy  is  probably  due  to  reflex  action.  It  is  a  reflex 
tropho-neurosis.     Even  a  neuralgic  joint  may  cause  an  atrophy. 


328 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


The  progno&is  is  good.  If  the  arthritis  gets  well  the  muscles 
are  also  restored. 

The  treatment  consists  of  electricity  and  gentle  massage  and  exer- 
cise.    Internal  treatment  must  be  directed  to  the  arthritis. 

Occupation  Muscular,  Atrophies. 

As  a  result  of  constant  overuse  muscles  sometimes  atrophy. 
This  applies  especially  to  the  smaller  muscles  of  the  hand.     Thus 


Am 


r'/l 


■;v' 


// 1  '■    .•  r  %  i  OS.     ^j&'fitfBkrff 

Fig.  148.— Showing  Changes  in  Arthritic  Muscular  Atrophy.     I,  Normal  fibre;  2, 
atrophied  fibre;  3,  vacuolated  fibre;  4,  connective-tissue  proliferation  (Darkschewitchj. 


there  occurs  an  atrophy  of  the  thenar  eminence  in  lapidaries  and  in 
persons  who  constantly  use  this  group  of  small  muscles. 

Typical  atrophies  of  this  kind  may  be  seen  in  persons  who  run 
elevators  and  who  have  constantly  to  grasp  the  rope  in  one  hand. 
The  biceps  sometimes  wastes  in  smiths  and  the  calf  muscles  in  ballet 
dancers.  In  most  cases  this  occupation  atrophy  of  muscles  reaches 
a  certain  stage  and  stops.  If  the  patient  is  given  rest,  recovery  takes 
place.  This  is  especially  true  if  the  patient  is  young  and  in  vigor- 
ous health.     In  other  instances,  the  simple  occupation  atrophy  will 


MUSCULAR    ATROPHIES   AXD    DYSTROPHIES.  329 

actually  pass  over  into  progressive  muscular  atrophy.  The  condition 
is  distinguished  from  a  true  progressive  muscular  atrophy  mainly 
by  the  fact  that  the  patient  has  none  of  the  aching  pains  and  vaso- 
motor symptoms,  such  as  sweating  in  the  arm,  and  very  little  if  any 
fibrillary  tremor.  The  electrical  reactions  are  the  same  as  in  spinal 
atrophies.  In  ordinary  occupation  atrophy  the  seat  of  the  disease 
is  probably  in  the  muscle  itself.  The  treatment  is  rest  and  tonics, 
the  careful  application  of  electricity,  and  hypodermic  injections  of 
strychnine. 


CHAPTER  XVI. 

TUMORS   AND   CAVITIES   OF   THE   SPINAL  CORD. 
Spinal  Tumors. 

Etiology. — Tumors  rarely  occur  in  the  spinal  cord.  The  com- 
monest age  is  thirty  to  fifty;  tubercle  occurs  earlier  (fifteen  to 
thirty-five — Herter)  and  lipoma  is  congenital.  Males  are  more  sub- 
ject than  females.  Tuberculosis,  syphilis,  and  cancer  predispose  to 
the  disease.  Injuries  and  exposures  appear  sometimes  to  excite  the 
growth  of  spinal  neoplasms. 

Symptoms. — These  vary  with  the  location,  character,  size,  and 
rate  of  the  growth  of  the  tumor.  No  definite  clinical  picture  can 
be  drawn.  The  symptoms  are  such  as  result  from  a  foreign  body 
slowly  and  progressively  irritating  and  destroying  the  roots  and  sub- 
stance of  the  spinal  cord.  Pain  appears  early  and  is  very  constant, 
continuous,  and  severe.  It  is  generally  referred  to  nerves  running 
out  from  the  cord  in  the  region  of  the  tumor;  a  girdle  sensation  is 
felt.  Numbness,  hyperesthesia,  and  later  anaesthesia  occur.  Ten- 
derness over  the  spine  and  rigidity  are  not  very  frequent.  The 
sensory  symptoms  are  usually  more  on  one  side,  but  may  become 
bilateral.  Spasm,  contracture,  and  exaggerated  reflexes  usually 
soon  develop,  involving  one  or  both  legs  or  an  arm  and  a  leg.  Later 
paraplegia,  atrophy,  loss  of  control  of  the  bladder  and  rectum,  and 
bedsores  follow,  and  death  ensues  from  exhaustion. 

When  the  disease  is  cervical  the  four  extremities  and  trunk 
muscles  may  be  gradually  involved,  and  there  are  rigidity  of  the  neck 
and  optic  neuritis.  If  lower  down,  there  develops  a  hemiparaplegia, 
later  a  complete  paraplegia,  usually  with  exaggerated  reflexes.  If 
the  tumor  is  in  the  lumbar  region  the  reflexes  are  sooner  lost  and 
the  sphincters  early  involved. 

A  rather  frequent  type  of  symptoms  caused  by  spinal  tumors  is 
that  known  as  a  Brown- Sequard  'paralysis  or  hemiparaplegia.  In  a 
typical  case  of  this  kind  there  are  paralysis  of  motion  and  muscle 
sense  on  the  side  of  the  lesion,  paralysis  of  cutaneous  sensation,  es- 
pecially of  pain  and  of  temperature  on  the  opposite  side.  On  the 
side  of  the  lesion  the  temperature  may  be  slightly  raised ;  there  is 
often  hyperesthesia,  and  reflex  action  is  increased.     There  may  be  a 


TUMORS   AND    CAVITIES    OF   THE    SPINAL    CORD. 


331 


band  of  anaesthesia  at  the  level  of  the  lesion  and  on  the  same  side 
(Figs.  149,  150). 

The  symptoms  vary  according  as  the  tumor  is  outside  or  inside 
the  dura.  The  common  extradural  forms  are  lipoma,  cancer, 
gumma,  and  sarcoma.  The  greater  amount  of  motor  and  sensory 
irritation,  the  evidence  of  some  vertebral  disease,  existence  of 
malignant  tumor  elsewhere,  the 
absence  usually  of  hemiparaple- 
gia,  characterize  extramedullary 
tumors.  The  common  forms  of 
intradural  or  medullary  tumor 
are  glioma  and  tubercle.  In 
these  cases  pain  and  spasm  and 
rigidity  are  less  common  in  the 
early  stage;  hemiparaplegia  is 
more  common.  A  secondary  my- 
elitis sometimes  develops. 

The  duration  of  the  disease 
ranges  from  three  to  five  years, 
the  average  being  two  or  three 
years. 

Pathology  mid  Pathological 
Anatomy. — All  forms  of  tumor 
occur,  but  the  commonest  are  gli- 
omata  and  sarcomata,  and  after 
this  fibromata,  myxomata,  gum- 
mata,  and  tubercles.  Cancer  is 
rare;  echinococcus  and  cysticer- 
cus  are  the  only  parasitic  tumors 
found.  Most  new  growths  start 
from  the  membranes,  the  next 
largest  numbers  from  the  cord, 
and  fewest  from  the  vertebrae. 


Fig.  149.— Showing  the  Condition  in  a 
Brown-Sequard  Paralysis  Due  to  a  Tr- 
mor  Growing  in  the  Left  Side  ok  the 
Spinal  Cord.  On  the  left  side,  bypersBS- 
J_ne  meningeal  tumors  are  thesia,  ataxia,  paralysis,  exaggerated  re- 
flexes. At  the  upper  limit  is  a  band  of 
anaesthesia.    On  right  side,  anaesthesia. 


mostly  sarcomata  and  their  vari- 
ous modifications,  fibroma,  en- 
chondroma,  carcinoma,  and  lipoma.  The  myelonic  or  intraspinal 
tumors  are  commonly  gliomata,  sarcomata,  tubercle,  and  syphilo- 
mata. 

Spinal  tumors  are  small  in  size,  ranging  from  one-fifth  to  one 
and  one-fifth  inches  (one-half  to  three  centimetres)  in  diameter. 
The  glioma  may  diffuse  itself  for  a  long  distance  through  the  centre 
of  the  cord,  forming  cavities  (syringo-myelia).     The  sarcomata  may 


12 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


likewise  be  irregularly  spread  along  the  surface  of  the  cord.  Spinal 
tumors  are  usually  single,  but  fibromata,  the  parasites,  and  sarco- 
mata ma}'  be  multiple. 

The  favorite  locations  for  spinal  tumors  are  just  below  the  mid- 
cervical,  the  upper  and  the  lower  dorsal  regions.  The  secondary 
changes  produced  by  tumors  are  softening,  hemorrhages,  second- 
ary degenerations,  and  inflammatory  reaction.  The  origin  and 
histology  of  spinal  tumors  do  not  differ  from  that  of  tumors 
elsewhere. 

TJie  Diagnosis. — The  disease  has  to  be  distinguished  from  verte- 
bral caries,  transverse  myelitis,  and  hypertrophic  pachymeningitis. 


Fig.  150.— showing  the  Mechanism  op  tubs  Production  of  a  Brown-SEquard  Paral- 
ysis. The  shaded  part  on  the  left  represents  the  lesion.  This  involves  the  pyramidal  tract  and 
motor  fibres  M,  causing  paralysis  and  spasm  on  the  same  side  ;  also  the  muscle  sense  nerves 
M  S  on  the  same  side  and  the  cutaneous  sensory  nerves  C  S  on  the  opposite  side. 

The  points  to  be  noted  as  regards  caries  are  the  absence  of  an  ex- 
ternal tumor  or  kyphosis;  the  small  degree  of  tenderness  and 
rigidity,  the  age,  and  absence  of  tubercular  diathesis.  The  progres- 
sive course,  beginning  with  pain,  followed  by  motor  and  then  sen- 
sory paralysis,  and  the  localization  of  the  symptoms  exclude 
myelitis.  The  differentiation  from  hypertrophic  pachymeningitis 
is  often  very  difficult. 

The  character  of  the  tumor  cannot  often  be  determined  certainly. 
The  probabilities  are  in  favor  of  sarcoma  or  glioma,  especially  in 
middle  life.  Syphiloma  may  be  suspected  from  the  history  and 
results  of  treatment.      Tubercle  is  very  rare. 

The  prognosis  is  bad  except  in  syphiloma,  and  even  here  it  may 
be  serious.  Tubercle  may  perhaps  cease  to  grow.  Surgical  inter- 
ference now  saves  the  life  of  some  patients. 

Treatment. — In  syphilitic  tumors  appropriate  remedies  may  do 
good  and  should  be  vigorously  used.  In  tubercle,  tonic  treatment, 
iodine,  and  cod-liver  oil  may  be  of  service.  In  gliomata  and  sar- 
comata, nitrate  of  silver  and  arsenic  may  be  tried.  In  other 
forms,  symptomatic  treatment  is  all  that  can  be  recommended  medi- 


TUMORS    AND    CAVITIES    OF   THE    SPINAL    CORD. 


333 


Gaily.      In  all  cases  of  spinal  tumor  surgical  interference  should  be 

considered ;  extradural  tumors,  if  taken  early,  can  be  removed  with 
great  benefit.  Even  in  medullar}'  tumors  enucleation  may  do  some 
good  in  the  early  stage.  Exploratory  operations  are  justifiable  if 
there  is  no  question  as  to  the  diag- 
nosis of  tumor.  The  mortality  from 
such  operation  in  capable  hands  is 
very  low,  though  it  is  more  danger- 
ous than  trephining  the  skull. 

CAVITIES   EN   THE   SPIXAL    CORD. 

The  cavities  of  the  spinal  cord 
are  known  as: 

1.  Hydromyelia. 

2.  Myelitic  cavities. 

:',.  Syringomyelia, 

Tli  ere  may  be  various  combina- 
tions of  those  processes,  the  most 
(■(minion  being  a  combination  of  hy- 
dromyelia and  syringomyelia. 

Hydromyelia. 

This  is  a  dilatation  of  the  cen- 
tral canal  of  the  cord,  the  cavity 
being  filled  with  fluid.  The  condi- 
tion may  be  associated  with  hydro- 
cephalus or  with  spina  bifida,  or  it 
may  be  independent  of  these  condi- 
tions. The  dilatation  may  be  cystic 
and  irregular,  or,  as  is  more  usual, 
extend  throughout  tin-  cord.  The 
dilatation  extends  more  posteriorly, 
because   the   posterior   columns   are 

formed  latest.  The  abnormality  may  be  slight  and  give  rise  to 
no  symptoms.  Or  a  pathological  process  like  a  gliomatosis  may 
develop  upon  it. 


Fig.  151.— Sarcoma  of  Spinal  Cord, 
Mid-i  Iebtical  Region. 


Myelitic  and  Hemorrhagic  Cavities. 


Such  cavities  may  be  formed  m  the  cord  by  a  central  excavating 
myelitis  or  by  small  hemorrhages.  These  cavities  are  usually  small. 
irregularly  distributed,  and  are  lined  with  connective  tissue.     They 

may  be   formed  in  rare  cases  in   connection    with    hydromyelia    or 
neoplasms. 


334 


DISEASES    OP   THE    NERVOUS    SYSTEM. 


Syringomyelia. 

Syringomyelia  is  a  disease  of  the  spinal  cord  characterized  by 
a  development  of  gliomatous  tissue  in  the  central  parts,  with  forma- 
tion of  cavities.  Clinically  the  disease  is  usually  characterized 
by  peculiar  disturbances  of  sensation  and  nutrition.  In  many  cases, 
however,  the  symptoms  are  atypical  and  the  disease  cannot  be 
recognized  during  life. 

The  description  here  given  corresponds  to  the  classic  manifesta- 
tion of  the  disease,  and  it  is  intended  to  refer  to  syringomyelia 
produced  by  gliomatosis  only. 

Etiology. — The  disease  is  rare,  but  over  two  hundred  cases  have 
now  been  reported.     It  is  more  frequent  than  amyotrophic  lateral 


1.  2. 

Fig.  152.— Distribution  of  Cutaneous  Anaesthesia  in  Syringomyelia.  1  shows  area 
of  analgesia,  2  shows  that  of  thermo-anaesthesia.  The  darker  shades  show  where  there  is 
anaesthesia  to  pain  and  temperature,  the  tactile  sense  being  unimpaired. 


sclerosis  and  less  frequent  than  multiple  sclerosis.  It  occurs 
oftener  in  men  than  in  women,  and  develops  early  in  life,  between 
the  ages  of  fifteen  and  twenty-five. 

It  occurs  especially  in  persons  who  follow  manual  occupations, 
such  as  butchers,  tailors,  etc.  Traumatism,  pregnancy,  and  infec- 
tious diseases  seem  occasionally  to  give  rise  to  it.  Heredity,  syph- 
ilis, and  alcohol  are  not  causal  factors. 

Symptoms. — The  disease  begins  insidiously  with  some  aching 
pains  in  the  neck  and  arms  and  paraesthesia  of  the  hands.  There  is 
soon  a  muscular  atrophy  of  the  hands  resembling  spinal  progressive 
muscular  atrophy,  with  perhaps  anaesthesia.     As  the  disease  pro- 


TUMORS   AND    CAVITIES    OF    THE    SPINAL    CORD. 


335 


gresses  the  weakness  and  atrophy  of  the  hand  muscles  become  more 
noticeable  and  gradually  extend  toward  the  trunk.  The  atrophy 
comes  on  in  both  extremities  at  about  the  same  time.  Fibrillary 
contractions  and  partial  degeneration  reaction  may  be  observed. 
Cutaneous  anaesthesia  of  the 
affected  hand  and  arm  to  tem- 
perature and  pain,  but  not  to 
touch,  takes  place;  and  this  is 
so  marked  as  to  be  almost  pathog- 
nomonic of  the  disease  (Fig. 
152). 

The  legs  do  not  become  af- 
fected until  late,  and  then  gen- 
erally show  a  spastic  paraplegia. 
The  throat  and  face  are  rarely 
involved.  There  is  a  scoliosis  of 
the  spine,  generally  in  the  dorso- 
lunibar  region(Fig.  153j. 

Vasomotor,  secretory,  and 
trophic  symptoms  are  promi- 
nent. The  hands  may  be  oede- 
matous  or  red  and  congested. 
Sweating  or  dryness  of  the  skin 
may  occur.  Eruptions  appear 
on  the  skin,  such  as  bull 83, 
herpes,  and  eczema.  Painless 
whitlows  attack  the  fingers  and 
may  destroy  the  terminal  pha- 
langes. Erosions  and  ulcera- 
tions also  occur.  The  nails  be- 
come dry,  brittle,  and  drop  off. 
Arthropathies  and  spontaneous 
fractures  have  been  observed. 
The  pupils  may  be  unequal  and 
the  bulb  retracted. 

Late  in  the  disease  symp- 
toms of  involvement  of  the  me- 
dulla develop.  At  this  time 
also  the  bladder,  rectum,  and 
genital  centres  are  attacked. 
The  disease  progresses  slowly 
for  years,  with  remissions  of 
various  degree. 

The  cardinal  symptoms  are  a  progressive  muscular  atrophy,  with 
a  peculiar  partial  anaesthesia,  trophic  disturbances,  and  scoliosis. 

Pathological  Anatomy. — The  seat  of  the  disease  is  the  substance 
of  the  cord.  On  opening  it  by  transverse  sections  one  finds  one  or 
more  cavities  extending  in  various  degrees  up  and  down.  The  must 
frequent  primary  site  is  the  cervical  swelling.     From  here  it  usually 


Fig.  153.— Showing  Curvatobe  of  Spine  in 
Syringomyelia  (Erb). 


336 


DISEASES   OF   THE   NERVOUS    SYSTEM. 


passes  down  and  may  reach  the  whole  length  of  the  cord.  It  also 
extends  upward  and  may  involve  the  medulla  and  the  nuclei  of  the 
cranial  nerves.     The  cavities  are  of  irregular  shape,  small  size,  and 


Fig.  L56. 

Figs.  154-150.— Sections  op  Spinal  Cord  at  Dif- 

fkisknt  Levels  in-  Syringomyelia  (Bruhl). 


12  D 


Fig.  157. — Syringomyelia,  show- 
ing cavity  with  gliomatous  tissue 
around  it,  and  ascending  and  de- 
scending degeneration. 


filled  with  a  liquid  like  the  cerebro-spinal  fluid.  They  are  situated 
oftenest  posterior  to  the  commissure  and  involve  one  or  both  pos- 
terior horns,  but  they  may  be  so  extensive  as  to  involve  almost  the 
whole  of  the  centre  of  the  cord  at  some  levels.  The  walls  are  usu- 
ally lined  by  a  membrane  and  surrounded  by  a  gliomatous  tissue 
(Figs.  154-157). 

This  membrane  is  composed  of  a  rather  dense  gliomatous  tissue. 


TUMORS    AND    CAVITIES    OF    THE    SPINAL    COED.  3o7 

It  may  be  absent  in  some  parts.  The  glia  cells  are  in  various  stages 
of  development  and  degeneration.  In  parts  of  the  cord  the  new 
growth  may  form  a  large  and  solid  mass  occupying  most  of  the 
centre  of  the  cord.  Small  hemorrhages  and  foci  of  myelitis  may  be 
present.  In  some  cases  there  is  evidence  of  a  dilated  central  canal, 
with  neuroglia  hyperplasia  of  the  walls  and  a  gliomatous  infiltration 
about  this.  The  epithelium  of  the  central  canal  may  form  part  of 
the  wall  of  the  cavity. 

1'ittliobxjij.- — At  about  the  sixth  week  of  foetal  life  the  central 
canal  of  the  cord  is  large,  diamond  shaped,  and  reaches  nearly  to 
the  anterior  and  posterior  surfaces  of  the  cord.  This  cavity  gradu- 
ally contracts  and  unites  in  the  middle,  the  anterior  part  forming 
the  central  canal  and  the  posterior  part  the  posterior  septum.  The 
posterior  part  may,  through  some  embryological  defect,  fail  to  close, 
and  a  congenital  cavity  may  be  left.  About  this  a  glioma  may  de- 
velop, and  we  have  syringomyelia.  The  central  canal  may  remain 
imperfectly  contracted,  and  a  syringomyelia  may  develop  in  con- 
nection with  it.  Probably  most  cases  of  syringomyelia  are  de- 
veloped on  the  basis  of  an  embryonic  defect. 

Gliomata  were  formerly  thought  to  be  practically  identical  with 
sarcomata.  It  is  believed  now,  however,  that  they  are  of  epiblastie 
origin,  and  like  nerve  cells  are  modifications  of  epithelial  tissue. 
This  tissue  in  its  normal  state  is  called  neuroglia.  It  is  a  nervous 
substance.  It  is  composed  of  small  cells,  round  or  of  irregular 
shape,  with  a  large  nucleus  and  fine  fibrillary  prolongations.  In 
glioma  these  cells  are  relatively  much  more  numerous,  while  the 
fibrillary  network  is  less  conspicuous.  There  is  considerable  varia- 
tion in  the  relative  richness  of  cells  and  fibres,  however.  When  the 
former  are  very  frequent  the  term  gliosarcoma  has  been  wrongly 
given  to  the  tumor.  The  glioma  is  penetrated  by  small  blood- 
vessels whose  walls  are  often  diseased,  so  that  minute  hemorrhages 
occur  and  the  glioma  becomes  stained  and  pigmented.  In  other 
cases  it  is  gray  or  yellowish  in  color. 

The  rich  cellular  proliferation  in  gliomata  has  suggested  an 
analogy  in  its  growth  to  that  of  inflammation,  and  the  term  gliosis 
is  used  as  analogous  for  neuroglia  to  sclerosis  of  connective  tissue. 
Gliosis  differs  from  sclerosis,  however,  in  the  fact  that  in  the  latter 
process  the  multiplication  of  fibres  dominates,  while  in  the  former 
it  is  the  cells;  besides  this,  in  gliosis  there  is  a  tendency  to  soften- 
ing and  formation  of  cavities,  and  all  nerve  fibres  disappear.  In 
sclerosis  some,  nerve  fibres  remain,  and  one  observes  the  presence  of 
granular  and  amyloid  bodies. 

Peculiar  Types. — 1.  The  disease  may  be  latent,  giving  rise  to 
very  few  symptoms  or  to  none  that  are  characteristic. 

2.  There  may  be  a  period  of  irritation  and  pain  in  the  ex- 
tremities followed  by  paraplegia,  with  few  sensory  troubles,  the 
course  suggesting  a  chronic  transverse  myelitis  or  a  I5rown-Sequard 
paralysis. 

3.  Theie  is  a  type  in  which  bulbar  symptoms  develop  earlv,  but 

22 


338  DISEASES   OF   THE    NERVOUS    SYSTEM. 

differing  from  ordinary  bulbar  paralysis  in  the  involvement  of  the 
trigeminus  and  other  cranial  nerves  not  commonly  attacked. 

4.  There  is  a  form  characterized  by  a  rather  rapid  ascending 
paralysis. 

None  of  these  types  can  ordinarily  be  recognized  during  life. 

5.  There  is  a  type  characterized  by  the  symptoms  of  muscular 
atrophy  with  analgesia  and  felons  (Morvan's  disease).  In  this  type 
there  is  probably  a  complicating  neuritis.  Some  assert  that  all 
-cases  of  Morvan's  disease  are  cases  of  syringomyelia,  but.  this  is  not 
proven. 

Diagnosis. — The  disease  is  distinguished  in  its  classical  form  by 
(1)  its  beginning  at  the  period  of  adolescence,  (2)  by  the  progressive 
muscular  atrophy  combined  with  the  peculiar  dissociated  disturb- 
ances of  sensibility,  (3)  by  the  trophic  disturbances  and  scoliosis. 

It  has  to  be  distinguished  from  progressive  muscular  atrophy 
and  dystrophy,  and  amyotrophic  lateral  sclerosis,  hypertrophic  cer- 
vical pachymeningitis,  chronic  transverse  myelitis,  Morvan's  dis- 
ease, and  anaesthetic  leprosy. 

The  sensory  and  trophic  disorders  and  scoliosis  enable  one  to 
distinguish  it  from  progressive  muscular  atrophy.  In  leprosy  the 
•dissociation  of  the  sensory  symptoms  is  not  present,  and  the  anaes- 
thesia is  distributed  along  the  course  of  the  nerves  or  in  sharply  cir- 
cumscribed plaques.  In  some  cases  the  peculiar  tubercular  disease 
of  the  skin  and  the  history  of  the  case  make  the  diagnosis  easy.  In 
leprosy,  also,  there  is  a  perineuritis,  and  the  enlarged  inflamed  nerves 
may  be  felt.  Portions  of  the  skin  may  be  excised  and  examined 
for  the  leprosy  bacillus.  As  regards  the  differentiation  from  Moi- 
van'  s  disease,  this  cannot  often  be  done.  Still  whitlows  are  rare  in 
ordinary  forms  of  syringomyelia.  Morvan's  disease  begins  in  one 
hand  and  slowly  extends,  with  remissions,  to  the  other.  Usually 
there  is  loss  of  tactile  as  well  as  thermic  and  pain  sense. 

The  prognosis  so  far  as  life  is  concerned  is  bad ;  but  the  disease 
has  often  a  long  course,  ranging  from  five  to  twenty  years,  and 
periods  occur  in  which  the  progress  of  the  disease  seems  arrested 
and  improvement  occurs. 

Treatment. — It  is  not  impossible  that  we  may  find  some  drug 
which  acts  specifically  on  gliomatous  tissue,  checking  its  growth. 
At  present  we  know  of  only  two  things  which  may  possibly  do  this : 
nitrate  of  silver  and  arsenic.  These  drugs  should  be  given;  and  for 
the  rest,  tonic  and  symptomatic  treatment  is  indicated. 

Functional  Disorders  of  the  Spinal  Cord. 

The  functional  disorders  of  the  spinal  cord  include  only  condi- 
tions of  irritation  and  depression,  to  which  the  names  of  spinal  ir- 
ritation and  spinal  exhaustion  or  spinal  neurasthenia  are  given. 
The  symptoms  of  these  states  are  sufficiently  described  under  the 
head  of  neurasthenia. 


TUMORS    AXD    CAVITIES    OF    THE    SPINAL   CORD. 


339 


Fig.  168.— Showing 

SIZE 


Cauda  Equina,  Natural 
(Mullen. 


The  Recognition  of  Diseases 
of  the  Cauda  Equina. 

Anatomy. — The  cauda  equina 
is  made  up  of  five  lumbar,  five 
sacral,  and  one  coccygeal  nerve 
roots.  They  lie  in  the  dura 
mater  forming  a  thick  bundle 
and  extending  down  the  verte- 
bral canal  for  14  cm.  They 
are  still  distinct  motor  and  sen- 
sory roots,  and  do  not  unite  till 
they  have  passed  out  of  the 
dura.  The  cauda  begins  at 
the  lower  tip  of  the  cord,  at 
the  level  of  the  lower  edge  of 
the  second  lumbar  vertebra. 
The  term  conus  is  applied  to 
the  lower  end  of  the  cord  and 
includes  the  parts  below  the 
second  sacral  segment.  The 
cord  here  becomes  much  small- 
er, loses  some  of  its  distinctive 
microscopical  structure,  and 
the  anterior  root  fibres  are 
smaller  and  less  numerous  than 
the  posterior  or  sensory. 

The  arrangement  of  the 
segments  and  nerves  is  shown 
in  Figs.  158  and  159.  The  ar- 
rangement of  the  visceral  cen- 
tres is  given  by  Mtiller  as  fol- 
lows: Second  sacral,  erection 
centre;  third  sacral,  ejaculation 
centre;  fourth  sacral,  bladder 
(detrusor)  centre;  fifth  sacral, 
sphincter-ani  centre.  The  dis- 
tribution of  the  sensory  nerves 
is  shown  in  the  Pigs.  160,  and 
161. 

Symptoms  and  Diagnosis. 
The  diagnosis  of  cauda  lesions 


340 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


involves  differentiation  of  (1)  lesions  of  the  lower  end  of  the  spinal 
cord ;  (2)  cauda  lesions  due  to  compression :  (3)  those  due  to  de- 
struction ;  (4)  lesions  of  the  peripheral  nerves. 

1.   Lesions  of  the  lower  end  of  the  cord  usually  come  on  rapidly, 
i.e.,  in  a  few  daj's  (myelitis,  softening,  hemorrhage);  there  is  little 


Fig.  159.— Showing  Arrangement  of  Segments  and  Nerves  of  Cauda  Equina 

(Peterson). 


pain  or  sensory  irritation,  and  later  there  is  dissociation  of  sen- 
sations. Fibrillary  contractions  and  involuntary  twitchings  of 
the  leg  muscles  occur.  Paralysis  rapidly  appears,  involving  the 
lower  limbs  in  accordance  with  the  segmental  distribution  of  the 
nerves.  It  is  flaccid,  and  is  followed  by  atrophy.  The  visceral 
centres  are  involved.  If  the  conus  is  not  implicated  the  paral- 
ysis does  not  seriously  involve  these  centres,  nor  the  muscles  of  the 


TUMORS    AND    CAVITIES    OF    THE    SPINAL    CORD. 


341 


pelvic  girdle.  The  motor  disturbances  are  more  conspicuous  and 
troublesome  symptoms  than  are  the  sensory  disturbances.  The 
cord  being  small  and  destroyed,  not  much  improvement  takes  place. 
2.  In  disease  of  the  cauda.  since  it  is  usually  a  tumor,  the  symp- 
toms come  on  slowly ;  in  injury.,  however,  the  onset  is  sudden.     There 


Lesion  at  second  lumbar  segment. 


I 

Lesion  at  third  lumbar  segment. 


Lesion  at  iiftii  lumbar  segment. 


Lesion  at  Orst  sacral  segment. 


Fi<;.   160.— Lesions  at  Different  Levels  of  the  Lumbar  and  Bacraj  Cord,  Showing 
Abbas  of  anaesthesia  (Mflller). 

is  often  severe  pain  felt  in  the  bladder  and  distribution  of  the 
Boiatdc  nerves,  and  usually  bilaterally.  There  follows  affceratime 
anaesthesia  in  the  ooui-seof  the  sciatic  nerves.  There  is  little  motor 
irritation,  and  paralysis  follows  slowly,  accompanied  with  pain,  the 
sensory  symptoms  hemg'all  along  in  the  foreground.  The  sexual, 
bladder,  and  rectal  centres  are  later  paralyzed.  The  oourse  is  pro- 
gressive unless  there  is  effective  operation  or  medical  interference. 
3.  The  symptoms  in  compression  of  the  cauda  without  destruc- 


342 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


tion  are  much  the  same  as  the  above,  but  there  is  less  motor  disturb- 
ance, and  there  may  be  no  involvement  of  the  visceral  centres. 

4.  In  lesions  of  the  peripheral  nerves,  the  trouble  (usually  neu- 
ritis or  injury)  comes  on  rather  rapidly.  There  are  sciatic  pains, 
tender  points,  the  lesion  may  be  only  unilateral,  the  pains  are  not 


lesion  at  second  sacral  segment. 


Lesion  at  third  sacral  segment. 


Lesion  at  fourth  sacral  segment. 

Fig.  161.— Lesions  at  Different  Levels  of  the    Sacral  Cord,   Showing  Areas  of 

anesthesia  (Miiller). 


so  severe,  and  there  is  no  marked  anaesthesia.  There  is  little  or 
no  paralysis  in  sciatica,  but  it  may  occur  in  neuritis.  There  is  no 
paralysis  of  the  visceral  centres ;  the  sensory  and  motor  symptoms 
go  together,  the  sensory  slightly  predominating ;  there  is  often  a 
history  of  sciatica  and  alcoholism,  or  injury.  Examination  may 
disclose  the  presence  of  a  tumor  or  of  some  disease  affecting  directly 
the  sciatic  plexus,  and  the  prognosis  is  favorable. 


CHAPTER   XVII. 


ANATOMY  AND   PHYSIOLOGY   OF   THE   BRAIN. 


Anatomy. — The  nervous  system  is  developed  from  a  hollow  tube 
formed  by  a  folding  of  the  epiblast.  The  brain  or  encephalon  grows 
out  from  its  anterior  part.  This  swells  into  three  cavities  called 
the  anterior,   middle,   and  posterior  cerebral  vesicles.      From  the 


Cc/timiss.vcst 
GlancLpineal. 


•hugeL 


helium 


Fig.  162.  Fig.  163. 

Fig.  162.— The  Cerebral  Vesicles. 

Fig.  163.— Further  Development  of  Vesicles.— J2,  Fore-brain  or  telencephalon:  />, 
'tween-brain  or  diencephalon ;  //,  mid-brain  or  mesencephalon;  III,  isthmus  and  meten- 
cephalon  or  hind-brain.  The  isthmus  is  not  indicated  separately  in  the  above  figure.  IV,. 
after-brain  or  myelencephalon  or  medulla  oblcngata  (Edinger). 

anterior  a  secondary  vesicle  develops;  the  posterior  divides  into 
two;  so  that  eventually  there  are  five  vesicles.  Out  of  them  the 
different  parts  of  the  braiu  are  formed. 

1.  From  the  anterior  vesicle  there  grow  the  cerebral  hemi- 
spheres, the  corpus  callosum  and  anterior  commissure,  fornix,  corpus 
striatum,  and  olfactory  lobes.  It  includes  also  the  anterior  part  of 
the  region  lying  under  the  thalamus  in  which  are  the  optic  chiasm 
and  pituitary  body.  These  structures  form  the  fore-brain  or  telen- 
cephalon. 

2.  From  the  posterior  part  of  the  primary  vesicle  come  the 
thalamus,  pineal  gland  (or  epithalamus),  geniculate  bodies  (or  meta- 
thalamus),  and  some  structures  lying  under  the  thalamus,  viz.,  the 


344 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


corpora  marnillaria,  and  Luys'  body.     These  parts  form  the  'tween- 
brain  or  diencephalon. 

3.  From  the  middle  cerebral  vesicle  there  grow  the  corpora 
quadrigemina  and  cerebral  peduncles,  with  the  red  nuclei  and  sub- 
stantia nigra.     They  form  the  mid-brain  or  mesencephalon. 

4.  From  the  fourth  vesicle,    which  is  a  secondary  vesicle  de- 


Fig.  161.  —Still  Further  Development  of  Vesicles.    The  cerebrum  is  being  formed  out 
of  the  first  vesicle  I2  (Edinger). 

veloped  from  the  third  primary,  come  the  "isthmus"  (which  in- 
cludes the  superior  cerebellar  peduncles  and  valve  of  Vieussens) 
and  the  "after-brain,"  composed  of  the  cerebellum,  its  middle  pe- 
duncles, and  the  pons.     This  part  is  also  called  the  metencephalon. 

5.  The  fifth  vesicle  (also  a  development  from  the  third)  forms 
the  medulla  oblongata,  or  after-brain,  or  myelencephalon. 

The  development  of  these  parts  is  shown  in  the  accompanying 
diagrams.  In  man  the  fore-brain  is  enormously  developed,  the 
'tween-brain  moderately  developed,  the  olfactory  lobes  are  atrophic, 


i^Vs**s^ 


Fig.  165.—  Further  Development.    The  dotted  lines  show  the  original  subdivision  into 

vesicles  (Edinger). 


the  mid-brain  is  almost  rudimentary,  the  hind-brain  well  developed, 
the  after-brain  relatively  not  much  developed.  The  divisions  above 
given  in  detail  seem  somewhat  academic  and  impractical  as  applied 
to  adult  human  brains,  but  the  main  features  are  not  so;  indeed 


ANATOMY    AND    PHYSIOLOGY    OF   THE    BRAIN.  345 

they  are  quite  essential  to  the  understanding  of  modern  anatomy. 
The  following  simplification  is  sufficient  for  the  student: 

Fore-brain      or      telen-  /  .-,      .     --,  ,       .     ,  ,  .  .  . 

rpnl  iIoti  I  Cerebral  hemispheres  and  corpora  striata 

^pSo?"1    ^   dlen   j"  °ptic  thalamus  and  geniculate  bodies. 

31  id  brain      or     mesen-  |  «      ,     ,  _  ,       ■.  ■,  ,  .        . 

renhalon  t  Cerebral  peduncles  and  corpora  quadrigemina. 

Isthmus  and  hind-brain  )  Cerebellum  and  its  peduncles, 
or  mesencephalon.         f  Pons. 

After-brain   or    myelen-  KIedulla. 
cephalon.  ) 

In  the  process  of  development  of  the  brain,  the  neural  canal  be- 
comes variously  enlarged  and  constricted,  until  the  ventricles  of  the 
brain,  the  foramina  of  Monroe,  and  the  aqueduct  of  Sylvius  are 
formed.  The  ventricles  are  the  two  lateral,  the  third,  fourth,  and 
fifth.  The  foramina  of  Monroe  connect  the  lateral  and  third  ven- 
tricles; the  aqueduct  of  Sylvius  connects  the  third  and  fourth  ven- 
tricles. 

Along  the  mesial  or  inner  surface  of  each  optic  thalamus  runs  a 
groove  known  as  the  fissure  of  Monroe.  This,  according  to  Minot, 
may  be  traced  along  the  sides  of  the  aqueduct  of  Sylvius  and  fourth 
ventricle  into  the  spinal  cord,  where  it  is  identical  with  the  line  of 
division  that  in  embryonic  life  separates  the  dorsal  from  the  ventral 
parts  of  the  cord,  forming  the  dorsal  and  ventral  zones  of  His.  Minot 
regards  this  line  of  demarcation  as  having  great  morphological  im- 
portance. All  parts  of  the  brain  and  cord  dorsal  to  it  form  a  dorsal 
zone  and  include  the  receptive  part  of  the  spinal  cord  and  medulla, 
as  well  as  the  cerebellum  and  cerebral  hemispheres.  This  dorsal 
zone  contains  only  nerve  cells  whose  processes  never  leave  the  nerve 
centres  to  form  nerves,  and  it  receives  all  the  entering  sensory 
nerve  fibres.     It  is  the  recipient  part  of  the  nerve  centre. 

The  ventral  zone  contains  all  cells  whose  processes  go  out  to  form 
peripheral  nerves;  it  has  also  some  cells  of  the  other  type,  but  it 
does  not  receive  any  entering  sensory  nerve  fibres.  It  is  the  efferent 
part  of  the  nerve  system  and  it  includes  the  anterior  and  part  of  the 
lateral  columns  of  the  spinal  cord,  as  well  as  the  ventral  parts  of 
the  mid-,  hind-,  and  after-brains.* 

The  different  segments  of  the  brain  are  composed  of  deposits  of 
nerve  cells  forming  gray  matter  or  ganglia,  and  of  strands  of  nerve 
fibres  connecting  these  ganglia.  Most  of  the  general  description  of 
these  parts  must  be  gotten  from  treatises  on  anatomy.  I  purpose, 
however,  to  enumerate  and  describe  the  various  ganglionic  deposits 
found  in  the  brain ;  then  show  the  various  tracts  connecting  them 
with  each  other  and  the  periphery. 

*  T  am  much  indebted  to  Prof.  C.  S.  Minot  for  details  regarding  this  con- 
ception  of  the  structure  of  the  nervous  system,  which  seems  to  me  to  deserve 
wider  recognition. 


346  DISEASES    OF   THE    NERVOUS    SYSTEM. 

The  sixteen  ganglionic  deposits  of  the  brain  are  arranged  in  the 
different  segments  as  shown  here : 

1.  Cerebral  cortex  (Fore-brain. 

2.  Corpus  striatum  [gSSS^SSo.   [Telencephalon. 

3.  Olfactory  lobes. 

4.  Optic  thalamus  ] 

5.  Corpora  geniculata    I  'Tween-brain. 

6.  Corpora  mamillaria   [  Diencephalon. 

7.  Luys'  body  J 

8.  Corpora  quadrigemina    )  Mid.brain. 

in   Se£  rCJ-  US  •  \  Mesencephalon. 

10.  Substantia  nigra  )  * 

11.  Cerebellar  cortex  )  Hind-brain 

12.  Cerebellar  nuclei    >tvT„+„^ „«i,oi™ 

13.  Pons  nuclei  \  Metencephalon. 

14.  Olivary  body    )  After.brain. 

The  Cortex  Cerebri  and  the  Convolutions. — The  gray  matter  of 
the  surface  of  the  brain  is  called  the  cortex  cerebri,  and  it  is  by  far 
the  largest  and  most  important  deposit  of  nerve  cells  in  the  body. 
The  cortex  is  from  2  to  4  mm.  (one-twelfth  to  one-fifth  of  an  inch) 
thick,  and  its  total  superficial  area  is  1, 800  to  2, 700  sq.  cm.  The 
area  of  gray  matter  lying  in  the  fissures  is  about  twice  that  lying 
on  the  surface  (Donaldson).  The  cerebral  cortex  is  arranged  in 
folds  or  convolutions  (gyri)  separated  by  fissures  or  sulci.  These 
fissures  divide  the  brain  also  into  lobes.  The  fissures  of  the  brain 
are  divided  into  primary  and  secondary.  The  former  are  perma- 
nent, and  present  little  change  in  size,  location,  or  direction.  The 
latter  are  variable  in  all  these  respects,  and  are  often  called  sulci  for 
purposes  of  distinction. 

The  primary  fissures  of  the  brain  are: 

The  longitudinal. 

The  transverse  or  choroidal. 

The  fissure  of  Eolando  or  central. 

The  fissure  of  Sylvius. 

The  parietal. 

The  parieto-occipital. 

The  calcarine. 

The  position  of  these  fissures  is  indicated  on  the  accompanying 
diagrams,  which  are  based  on  descriptions  of  Eberstaller.  I  have 
not  space  to  give  detailed  descriptions. 

The  secondary  fissures  or  sulci  will  be  enumerated  in  describing 
the  lobes.  They  are  divided  into  the  typical  or  more  or  less  con- 
stant and  the  atypical  or  tertiary  fissures. 

The  primary  fissures  divide  the  cerebrum  into  various  portions 
called  lobes.     The  lobes  are: 

Frontal.  The  central  or  island  of  Eeii. 

Parietal.  Olfactory. 

Temporal.  Limbic. 

Occipital. 


ANATOMY   AND    PHYSIOLOGY   OF   THE    BRAIN. 


347 


There  are  eight  fissures  and  seven  lobes. 

Tli e  frontal  lobe  is  limited  behind  by  the  fissure  of  Rolando,  and 
on  the  median  surface  by  the  calloso-marginal  or  subfrontal  fissure 
and  its  ascending  branch.  It  has  the  following  sulci :  1.  Superior 
frontal  and  superior  precentral.  2.  Inferior  frontal  and  inferior 
precentral.     3.   Olfactory.     4.   Triradiate. 

In  the  frontal  lobe  are  the  following  convolutions :  1.  Pre- 
central or  ascending  frontal,  having  on  its  median  surface  (a)  the 
paracentral  lobule.  2.  First  or  superior  frontal.  3.  Second  or 
middle  frontal.     4.  Third  or  inferior  frontal  (Fig.  166). 

The  parietal  lobe  is  limited  behind  by  the  parietooccipital  and 


Fig.  166.— Left  Hemisphere,  from  without. 


anterior  occipital  fissures,  below  on  its  outer  surface  by  the  Sylvian 
fissure  and  a  line  drawn  back  from  its  upper  end  to  the  lower  part 
of  the  anterior  occipital.  In  front  it  is  limited  by  the  fissure  of 
Rolando.  On  its  median  surface  it  is  limited  in  front  by  the  as- 
cending branch  of  the  calloso-marginal  or  subfrontal  fissure,  behind 
by  the  parieto-occipital,  and  below  by  the  subparietal  fissure. 
Its  important  sulci  are:  1.  The  parietal  or  interparietal.  2.  The 
postcentral.  The  convolutions  formed  are,  on  the  convex  surface: 
1.  The  postcentral  or  ascending  parietal.  2.  The  superior  parietal 
lobule,  having  on  its  median  surface  (a)  the  quadrate  lobule  or  prae- 
cuneus.  3.  The  inferior  parietal  lobule,  which  is  composed  of  (a) 
the  supramarginal  gyrus,  (b)  the  angular  gyrus.  These  latter  gyri 
are  variously  described,  but  it  is  best  to  regard  one,  (a). the  supra- 
marginal,  as  that  surrounding  the  posterior  end  of  the  fissure  of 
Sylvius;  the  other,  (b)  the  angular,  as  that  beginning  at  the  upper 
limit  of  the  first  temporal  fissure  and  extending  back  as  far  as  the 
anterior  occipital  fissure. 

The  Occipital  Lobe. — This  is  limited  on  its  convex  surface,  an- 
teriorly, by  the  parieto-occipital  fissure,  laterally  to  this  by  the 
anterior  occipital  and  inferior  occipital  fissures.     These  in  apes  form 


348 


DISEASES    OF   THE    NERVOUS   SYSTEM. 


a  single  continuous  fissure  sharply  separating  the  occipital  from  the 
other  lobes.  On  its  median  surface  the  parietooccipital  fissure 
limits  the  lobe  in  front.  On  the  under  surface  the  anterior  edge 
of  the  tentorium  about  marks  the  anterior  limit. 

The  sulci  are:  1.   The  transverse  occipital  (ape  fissure  of  some 
writers).      2.   The  superior  or  lateral  occipital.      3.  The  inferior 


frontal  p0^ 


Lob. 
occipit. 

Fig.  167.— The  Cerebrum,  from  above. 


occipital.  On  the  median  surface:  4.  The  calcarine,  which  joins 
the  parieto-occipital.  5.  The  inferior  occipitotemporal  or  fourth 
temporal. 

The  convolutions  on  the  convex  surface  are:  1.  The  superior 
occipital.  2.  The  middle  occipital.  3.  The  inferior  occipital.  4. 
The  descending  occipital.  On  the  median  surf  ace  we  find :  5.  The 
cuneus.     6.  Descending  occipital. 

The  Temporal  Lobe. — The  convex  or  lateral  surface  shows  the 
following  sulci:  1.  The  first  temporal  or  parallel  sulcus.  2.  The 
second  or  middle  sulcus.  On  the  under  and  median  surfaces  are: 
3.  The  third  or  inferior  temporal  sulcus.  4.  The  fourth  temporal 
or  inferior  occipito-temporal  or  collateral  sulcus,  which  extends  into 
the  occipital  lobe.     5.   The  hippocampal  sulcus. 

The  convolutions  are:  1.  The  first  temporal  convolution.  2. 
The  second  temporal  convolution.  3.  The  third  temporal  convolu- 
tion.    4.  The  lateral  occipito-temporal  or  fusiform  convolution.     5. 


ANATOMY    AND    PHYSIOLOGY    OF   THE    BRAIN. 


349 


The  median  occipitotemporal  or  lingual  convolution.  6.  The  hip- 
pocampal  convolution,  which  is  an  extension  of  4  and  5.  7.  The 
uncinate  convolution,  which  is  an  extension  of  6. 

The  Island  of  Hell  (lobus  centralis,  lobus  caudicis). — This  has  a 


Fig.  lt>8.— Right  Hemisphere,  from  within. 

circular  sulcus  surrounding  it,  and  several  more  or  less  short  sulci 
dividing  it  into  from  five  to  seven  short  gyri. 

The  limbic  lobe,  if  described  as  a  separate  lobe,  is  made  to  in- 


Fk..  189.    I'MiH!  Surface  <>k   BBAih.     LOT,  lateral  occipitotemporal  or  fusiform  lobe; 
i/'/V,  median  ocdplto-temporai' or  lingual  toft©. 


elude  anteriorly  the  gynw  fornicators  or  gyrus  cimguii;  baek  of  this 

the  isthmus:   thru  the  hippocuinpul,  uncii la t <-,  ;iikI  dentate  convolu- 
tions (  Fig.    168  I. 


350  DISEASES    OF   THE    NERVOUS   SYSTEM. 

The  olfactory  lobe  is  rudimentary  in  man.  Its  position  is  shown 
in  the  diagrams. 

The  operculum  is  the  part  of  the  brain  that  overlaps  the  island 
of  Reil.  It  consists  of  a  fronto-parietal  part,  formed  by  the  lower 
ends  of  the  two  central  convolutions,  a  frontal  part  formed  by  the 
base  of  the  inferior  frontal  convolution,  and  a  temporal  part  formed 
by  the  tip  of  the  temporal  lobe. 

The  cuneus,  precuneus,  and  paracentral  lobule  are  important 
subdivisions  on  the  median  surface  of  the  brain.  Their  position  and 
boundaries  are  shown  in  the  cuts  (Fig.  168 ). 

Microscopical  Anatomy  of  the  Convolutions. — The  cortex  of  the 
cerebrum  is  composed  of  nerve  cells,  a  network  of  nerve  fibres  and 
processes,  and  of  neuroglia  tissue.  Superimposed  upon  it  is  a  very 
vascular  membrane,  the  pia  mater,  which  sends  a  rich  plexus  of 
vessels  into  it.  We  shall  proceed  to  study  :  1st,  the  structure  and 
arrangement  of  the  nerve  and  neuroglia  cells;  2d,  the  arrangement 
and  connections  of  the  nerve  plexuses.  On  both  these  points  new 
facts  are  being  constantly  added,  and  the  present  description  must 
be  in  many  respects  only  provisional. 

1.  The  cells  are  arranged  to  a  certain  extent  in  layers.  In  the 
outer  layer,  next  the  pia  mater,  is  a  deposit  of  neuroglia  tissue  con- 
taining also  peculiar-shaped  nerve  cells,  called  cells  of  Cajal. 
Beneath  these  are  small,  somewhat  irregularly  shaped  pyramidal 
cells  (angular  cells  of  Lewis) ;  next  come  large  pyramidal  cells ;  and 
deepest  of  all  irregularly  shaped  cells  (including  the  granule  cells 
of  Lewis)  and  spindle-shaped  cells  (Fig.  170). 

In  the  above  I  have  described  four  layers  of  cells,  and  this  may 
be  considered  the  type.  Some  anatomists  describe  five  typical 
layers,  the  fifth  being  made  by  a  subdivision  of  the  fourth  (by 
Meynert)  or  of  the  third  (by  Lewis).  The  common  four-layer  type 
is  found  in  the  central  convolutions  and  frontal  lobe.  In  the  oc- 
cipital region  there  are  six  (Lewis)  or  eight  (Meynert)  layers  de- 
scribed. These  are  formed  by  the  interposition  of  granule  cells 
which  subdivide  the  third  layer.  Various  types  of  cortex  are  de- 
scribed, depending  upon  the  different  degree  of  development  of  the 
cell  layers  and  upon  the  fibre  arrangements.  The  common  or  motor 
type,  as  has  been  stated,  has  four  layers.  The  large  pyramidal 
cells  are  here  numerous  and  are  arranged  in  clusters.  The  sensory 
type  has  at  least  five  layers,  as  seen  in  the  occipital  cortex,  and 
here  the  large  pyramidal  cells  are  few  and  isolated. 

The  pyramidal  cells  everywhere  are  arranged  with  their  apices 
pointing  to  the  periphery  (Fig.  170).  They  give  off  apical,  lateral, 
and  basal  processes.  The  basal  process  of  the  pyramidal  cells  is 
continued  as  an  axis  cylinder.  Some  of  them  pass  down  into  the 
white  matter;  others  turn  up  and  enter  the  fibre  systems  of  the 
cortex.  The  spindle  cells  point  toward  the  periphery  also,  except 
at  the  bottom  of  the  sulci,  where  they  lie  parallel  to  the  surface. 
Their  processes  connect  neighboring  areas  and  are  called  association 
fibres. 


AX  ATOMY   AND    PHYSIOLOGY    OF   THE    BKAIN. 


351 


ri 


,i^lliLLi~ 


XVI 


k       n 


W 


vH.mi'j- 


BUll'ufU 


JX 


m 


-ti 


R2 


,N 


m. 


I -a 


■cif*-/ 


SI 


VI- 


sMf^j 


Tangential  fibres. 


Striae  of  Bechterew  and 
de  Kaes. 


Supperradiary  network 

(of  the  second  and 

third  layers). 


Striae  of  Baillarger. 


Interradiary  network 
(of  the  third  and 
fourth  layers). 


Meynert's  intracortical 
association  fibres. 


Subcortical  association 
fibres. 


Fig.  170.  Fig.  171. 

Fig.  170. -Showing  the  Different  Cellular  Layers  ok  the  Brain  Cortex  (after 
Cajah.  M,  neuroglia  layer;  pPy,  small  pyramidal  layer  ;  /'//,  large  pyramidal  layer;  Pm, 
irregularly  shaped  cells.    The  cells  of  Cajjal  can  be  seen  In  the  layer  at. 

Fio.  171.  -  Showing  the  Layers  ok  Nerve  FIBRES.  Practically  the  tangential  fibres 
and  the  striae  of  Baillarger  are  the  only  layers  that  show  distinctly. 


352  DISEASES    OF    THE    XEUVOI'S    SYSTEM. 

The  small  pyramidal  and  spindle  cells  measure  about  10  x  18  />.; 
the  large,  20  x  40  ;/.  (yo^rr  x  ttu,t  in-)-  There  are  in  the  upper  cen- 
tral and  paracentral  convolutions  giant  cells  (of  Betz)  which  meas- 
ure 125  x  55  p.  (^1^  x  -g-i-g-  in.).     (See  Plate.) 

Despite  the  great  variety  and  complexity  of  the  cortex,  it  is 
probable  that  there  are  but  three  principal  classes  of  cells :  (1)  those 
which  receive  nervous  impulses  and  which  lie  chiefly  in  the  second 
and  granule  layers ;  (2)  those  which  associate  and  co-ordinate  these 
impulses,  and  which  partly  lie  in  the  first  and  partly  deep  In  the 
fourth  layers  (cells  of  Cajal  and  spindle  cells);  and  (3)  those  which 
discharge  impulses  and  which  lie  in  the  third  layer  (large  pyramidal 
cells). 

2.  The  fibres  and  plextcses  of  the  cortex  are  composed  of  proc- 
esses from  the  nerve  cells  and  terminals  coming  in  from  the  white 
matter.  They  collect  into  several  close  networks.  One,  lying  in 
the  neuroglia  layer  and  running  parallel  to  the  surface,  is  called 
the  tangential  layer  of  fibres;  a  second  layer  runs  among  the 
large  pyramidal  cells,  forming  the  outer  stripe  of  Badllarger-;  and  a 
third  layer,  beneath  this,  is  called  the  inner  stripe  of  Baillarger. 
Besides  these,  there  are  radiating  fibres,  running  in  from  the  white 
matter  and  forming  interradial  and  superradial  networks  (Fig.  171). 

The  cortical  gray  matter,  as  will  thus  be  seen,  contains  layers  of 
nerve  cells,  into  which  nerve  fibres  penetrate.  These  terminate,  as 
do  all  fibres,  in  end  brushes,  which  surround  the  receptive  or  sen- 
sory cells.  An  enormous  number  of  fine  fibres  is  given  off  by  the 
cells ;  some  of  these  form  layers  in  the  cortex  and  connect  neighbor- 
ing parts,  others  run  out  and  connect  more  distant  parts  or  pass 
down  to  lower  levels.  There  are  thus  three  kinds  of  fibres — affer- 
ent, associative,  and  efferent — just  as  there  are  three  types  of  cells, 
and  since  nerve  cells  and  fibres  are  really  parts  of  the  same  unit — 
the  neuron — there  are  practically  three  kinds  of  neurons  in  the 
cortex. 

The  different  convolutions  and  lobes  of  the  brain  are  connected 
with  each  other  by  association  fibres  and  commissural  fibres  and  to 
the  ganglionic  masses  below  them  by  projection  fibres.  The  asso- 
ciation fibres  consist  of  short  fibres  connecting  neighboring  convo- 
lutions and  of  long  tracts  which  connect  neighboring  or  distant 
lobes. 

The  short  association  fibres  are  numerous;  they  lie  close  be- 
neath the  gray  matter  and  connect  convolutions  of  the  same  lobes. 
The  course  of  many  of  the  long  association  paths  is  not  yet  well 
known.  The  occipital  lobe  is  connected  by  long  tracts  to  the 
temporal  lobe,  anil  perhaps  slightly  to  the  inferior  parietal  lobe 
(H.  Sachs).  The  temporal  lobes  are  connected  only  to  the  occipi- 
tal. The  frontal  lobe  is  apparently  connected  with  the  parietal. 
Its  connection  with  the  temporal  is  denied  (H.  Sachs).  All  the 
lobes  of  the  two  halves  of  the  brain  are  connected  with  each  other 
by  commissural  tracts  in  the  corpus  callosum  and  anterior  commis- 
sures.     I  will  describe  the  projection  fibres  later. 


ANATOMY    AXD    PHYSIOLOGY    OF   THE    BKAIX.  353 

Tin-:  Cokpojia  Striata  which,  form  the  second  ganglionic  mass 
to  be  studied  are  composed  of  two  parts :  the  caudate  nucleus  and 
lenticular  nucleus.  These  two  nuclei  are  separated  dorsally 
by  the  "white  fibres  forming  the  internal  capsule.  Below  they 
are  continuous.  Their  shape  and  relations  are  not  easily  appre- 
ciated except  by  actual  inspection  of  specimens.  They  are  indi- 
cated in  the  accompanying  figures  (172-174).  The  head  of  the 
caudate  nucleus  is  connected  with  the  gray  matter  of  the  anterior 
perforated  space.  The  tail  extends  into  the  temporal  lobe,  where  it 
is  continuous  with  the  gray  matter  of  the  cortex,  called  at  this  point 


Fig.  1T~.  —  Longitudinal  Section*,  showing  the  lenticular  (hi)  and  caudate  nuclei  (en) 
separated  by  the  internal  capsule  ((f),  the  corpus  callosum  (cc),  the  anterior  commissure 
(ac),  the  optic  tract  (II.'),  the  optic  thalamus  (th),  the  corpora  geniculata  (.7),  and  the 
pulvinar  (p),  the  crusta  (cr),  the  tegmentum  (fg),  pons  (P),  and  cerebellum  (C);  p,  puta- 
men;  g,  globus  pallidus  (G.  Stewart/. 

the  amygdalum,  and  with  the  claustrum.  The  lenticular  nucleus  is 
also  continuous  with  the  gray  matter  of  the  anterior  perforated 
space.  It  is  divided  into  three  portions;  the  external  is  called  the 
putamen,  the  two  inner  the  globus  pallidus.  These  parts  are  sepa- 
rated by  white  fibres.  The  caudate  nucleus,  putamen,  and  prob- 
ably all  of  the  corpus  striatum  are  modifications  of  the  cerebral 
cortex. 

The  corpus  striatum  lias  (1)  fibres  which  pass  to  it  from  the 
cortex,  (2)  fibres  which  pass  through  it  from  the  frontal  and  parietal 
cortex,  (."»)  fibres  which  originate  in  it  connect  its  different  parte, 
and  go  to  parts  below  it.  1.  The  fibres  joining  the  ganglion  to  the 
oortes  are  few  and  merely  associative.  2.  The  fibres  which  pass 
through  it  pass  chiefly  into  the  dorsal  part  of  the  cerebral  peduncles 
(or  tegmentum)  and  are  connected  with  the  sensory  tracts  there. 


354  DISEASES   OF   THE   NERVOUS   SYSTEM. 

3.  Fibres  which  originate  in  the  caudate  nucleus  and.  putamen  col- 
lect together  and  join  with  the  cortical  fibres  to  form  the  "len- 
ticular loop"  (ansa  lenticularis) .  Some  go  to  the  subthalamic 
(Luys'  body)  and  optic  thalamus ;  most  go  to  the  inferior  olives  and 
thence  connect  with  the  cerebellum.  Some  perhaps  go  to  the  pos- 
terior longitudinal  bundle,  which  is  a  band  of  commissural  fibres 


Fig.  173. —Horizontal  Section,  showing  the  frontal  (i^),  temporo-sphenoidal  (TS), 
and  occipital  lobes  CO),  with  their  gray  and  white  matter,  the  island  of  Reil  (R),  its  gray 
and  white  substance,  the  claustrum  (cZ),  the  external  capsule  (ec),  the  lenticular  nucleus 
(In),  the  caudate  nucleus  (en),  the  internal  capsule  (ic),  the  optic  thalamus  (th),  the  pul- 
vinar  (p),  the  corpus  callosum  (cc),  the  anterior  and  posterior  commissures  («c  and  pc), 
the  lateral  ventricle  (IF),  with  the  choroid  plexus  (ch)  (G.  Stewart). 

that  connect  together  the  cranial  nerve  nuclei  in  the  medulla. 
Fibres  connect  the  caudate  nucleus  and  putamen  with  the  globus 
pallidus. 

The  corpora  striata  are  relatively  rudimentary  ganglia  in  man. 
They  contain  sparsely  distributed  multipolar  and  fusiform  cells, 
two"  ^°  Tiro  *n'  ni  diameter,  the  larger  being  in  the  lenticular 
nucleus.     They  are  chiefly  of  the  second  or  Golgi  type. 

The  Optic  Thalami. — These  ganglia  form  the  chief  part  of 
the  'tween-brain.  They  lie  at  the  base  of  the  brain,  posterior  and 
internal  to  the  corpora  striata.     They  are  continuous  with  each 


ANATOMY    AND    PHYSIOLOGY    OF   THE    BRAIN.  355 

other  by  means  of  the  middle  gray  commissure.  The  upper  or 
dorsal  surface  forms  part  of  the  wall  of  the  lateral  ventricles ;  the 
mesial  surface  forms  the  lateral  wall  of  the  third  ventricle.  Ex- 
ternally is  the  band  of  white  fibres  called  the  internal  capsule;  be- 
low this  is  a  rather  large  mass,  the  red  nucleus,  external  to  a  small 
gray  nucleus  called  the  subthalamic  ganglion  (Luys'  body).  Around 
and  below  these  is  a  complex  network  of  fibres  called  the  stratum 
intermedium.  Below  this,  on  the  base  of  the  brain,  are  the  corpora 
mamillaria  (Fig.  175).  The  thalamus  is  composed  of  six  nuclei — 
the  anterior,  lateral,  median,   ventral,  posterior,  and  the  pulvinar 


Fig.  174.  —Section  through  the  Middle  of  the  Basal  Ganglia,  Precentral  (AF'), 
and  Part  of  Postcentral  (AP )  Convolutions,  and-  (TS)  Temporal  Lobe.  It  shows 
the  corpus  callosum  (cc),  the  fornix  (6),  the  fifth  ventricle  (Y),  lateral  ventricles  <LV), 
small  part  of  thalamus  (th),  internal  capsule  (ic),  caudate  nucleus  (ch),  lenticular  nucleus 
(In),  external  capsule  (ee),  claustrum  (cl)  (G.  Stewart). 

(Fig.  172,  ]>.  353).  Besides  these  there  is  on  the  median  surface  a 
small  ganglion  called  the  g.  habenulse.  The  optic  tracts  wind 
around  the  posterior  and  outer  edge  of  the  thalamus;  and  con- 
nected with  these  and  the  thalamus  are  two  other  ganglia,  the  ex- 
ternal or  lateral  and  internal  or  median  geniculate  bodies.  Thus  the 
thalamus  is  in  close  anatomical  relations  with  five  small  ganglia; 
three  below  it — the  corpus  mamillare,  red  nucleus,  and  subthala- 
mic ;  two  postero-external  to  it,  the  geniculate  bodies.  To  these 
may  be  added  the  corpora  quadrigemina.  The  thalamus  is  com- 
posed of  multipolar  nerve  cells  rather  more  numerous  and  larger 
than  those  in  the  striatum,  but  not  grouped  closely  together.  Starr 
describes  a  small  stellate  multipolar  cell  and  a  large  multipolar  cell. 
There  are,  besides  these,  cells  of  the  second  or  Golgi  type  which 
have  associative  functions.     The   optic   thalamus  is  composed   of 


350 


DISEASES   OF   THE    XERVOUS    SYSTEM. 


nerve  cells  whose  neuraxons  pass  up  to  the  cortex;  and  of  the  ter- 
minal fibres  from  neurons  lying  in  the  cortex  and  in  the  sensory 
cranial  and  spinal  nuclei  below.     Between  these  are  the  Golgi  or 


"~^iPW~~7 


Cerebellum 


A.  opticus 
Hyoophy 


^'vsenbaO^ 


Fig.  175.—  Showing  the  Relations  of  the  Optic  Thalamus  to  Other  Parts  CEdinger). 

associative  cells  which  unite  these  various  afferent  and  efferent 
neurons.  The  optic  thalamus  is  a  terminal  station  of  numerous 
fibres  of  sensation  coming  from  the  medulla  and  cord;  it  is  also 


Fig.  176.— Section  through  the  Corpora  Quadrigemina  (Q),  Tegmentum  ( TG),  and 
Cerebral  Peduncles.    88,  Substantia  nigra;  Pp.  peduncles;  ^-l.S',  aqueduct  of  Sylvius. 


the  place  of  origin  of  cells  which  send  processes  to  the  cortex  and 
the  receiving  centre  of  fibres  coming  from  the  cortex.  It  is 
therefore  a  very  important  sensory-motor  ganglion  connected  with 


ANATOMY    AND    PHYSIOLOGY    OF   THE    BRAIN.  357 

the  reception  and  distribution  of  sensory  and  motor  influence  and 
with  the  automatic  and  refex  movements. 

The  Corpora  Quadrigemina.  —  The  mid-brain  contains  as  its 
chief  ganglia  the  corpora  quadrigemina.  These  consist  of  four 
tubercles,  two  anterior  and  two  posterior  (Fig.  175).  In  man  they 
are  rudimentary  in  structure  and  relatively  unimportant  in  function. 
In  man  also  the  posterior  tubercles  are  developed  more  relatively 
than  in  most  lower  animals.  They  together  measure  about  14  mm. 
(£  in.)  in  sagittal  direction.     In  front   lie   the  pineal   gland  and 


Fig.  177.—  Showing  Some  of  the  Relations  of  the  Corpora  Quadrigemina  and 
Optic  Thalamus  to  Other  Parts  or,  optic  thalamus;  GQ,  corp.  quad. ;  i;.\.  red  nu- 
eleus;  8,  Luys'  body;  82Tt  substautia  nigra;  L,  sensory  fibres  from  cord;  CM,  corp. 
iiiamillare. 

third  ventricle;  beneath  are  the  aqueduct  of  Sylvius  and  the  struc- 
tures of  the  upper  pons  and  cerebral  peduncles.  This  inferior 
boundary  is  shown  by  the  dotted  line  in  the  cut  (Fig.  176).  Micro* 
scopic;illy  the  anterior  lobes  consist  of  layers  suggesting  a  cortical 
type  (Spitzka);  the  outermost  is  made  up  of  optic-tract  fibres,  the 
next  is  a  thin  layer  of  small  nerve  cells,  then  optic  fibres  again,  and 
deepest  of  all  a  layer  containing  a  few  large  cells.  The  posterior 
lobes  are  more  homogeneous  and  contain  small  multipolar  cells  and 
a  ganglion. 

The  figures  172  to  174  show  the  relationships  of  the  basal 
ganglia  and  other  parts. 

The  Substantia  Nigvu,  —  Below  the  corpora  quadrigemina  and 
lying  between  the  upper  sensory  part  (teffme»twn^  of  the  peduncles 


358 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


of  the  brain  and  the  lower  motor  part  (crusta)  is  the  substantia 
nigra.  It  contains  large  multipolar,  angular,  and  fusiform  cells 
deeply  pigmented  (Fig.  176). 

The  Red  Nucleus. — Dorsal  to  the  s.  nigra  and  at  about  its  middle 
extent  is  the  red  nucleus.  It  is  spherical  or  oblong,  very  vascular, 
and  contains  numerous  small  cells. 

The  subthalamus  (Luys'  body)  lies  more  dorsally  but  in  about 
the  same  plane  as  the  substantia  nigra.  It  measures  about  i-  by  \ 
inch,  and  contains  a  few  cells  and  a  very  fine  plexus  of  nerve  fibres. 

The  position  and  relation  of  these  bodies  are  shown  in  Fig. 
174. 

The  nuclei  of  the  pons  Varolii  are  irregularly  distributed  masses 
of  nerve  cells  lying  deep  among  the  longitudinal  and  transverse 


Fig.  178.  — Sho^wtng  the  Lobes  and  Other  Subdivisions  op  the  Cerebellum,  Dorsal 

Surface  (Edinger). 

fibres.  A  special  nucleus  lying  low  down  in  the  pons  is  known  as 
the  superior  olive.  In  the  after-brain  or  medulla  we  have  the  gray 
matter  of  the  floor  of  the  fourth  ventricle  and  its  cranial  nerve 
nuclei,  the  olivary  bodies,  and  certain  small  deposits  of  gray  matter 
called  the  nodal  nuclei. 

The  Cerebellum  in  man  consists  of  a  median  portion  or  vermis 
and  two  lateral  hemispheres.  It  is  connected  to  the  cord  and  rest 
of  the  brain  by  anterior,  middle,  and  posterior  peduncles.  It"-  is 
composed  of  an  external  layer  or  cortex  of  gray  matter,  of  cent_al 
white  matter,  and  central  ganglia.  The  gray  matter  lies  in  very 
close,  narrow  folds,  producing  with  the  white  matter  an  appearance 
on  section  called  the  arbor  vitce.  The  vermis  and  hemispheres  are 
divided  by  sulci  into  a  number  of  lobes  and  lobules.  The  vermis  is 
divided  into  superior  and  inferior  portions.  Its  further  subdivisions 
and  those  of  the  hemispheres  are  shown  in  the  cuts  (Figs.  178,  179). 
In  the  white  matter  of  either  hemisphere  is  a  nucleus  of  small 
multipolar  cells,  the  corpus  dentatus  or  ciliary  body.  To  the  median 
side  of  this,  and  belonging  structurally  to  it,  is  a  small  nucleus,  the 


ANATOMY    AXD    PHYSIOLOGY    OF   THE    BRAIX. 


359 


emboliform  nucleus.  In  the  inferior  vermis  is  a  collection  of  larger 
multipolar  cells,  the  nucleus  fustigium  or  tegmental  nucleus;  just 
to  the  outer  side,  between  it  and  the  emboliform  nucleus,  is  a  small 
collection  of  cells,  resembling  those  of  the  n.  fastigii,  called  the 
nucleus  globosus. 

The  Cerebellar  Cortex. — If  a  section  be  taken  through  the  gray 
matter  of  the  cerebellum,  it  will  be  found  to  be  composed  of  two 


Fig.  179. —Cerebellum,  Ventral  Surface  (Edinger). 

layers,  an  outer,  or  molecular,  and  an  inner,  or  granular,  layer. 
Each  of  these  layers  contains  a  large  number  of  peculiar-shaped 
nerve  cells,  and  very  rich  plexus  of  nerve  fibres.     The  molecular 


Fio.  180.— Section  THROUGH  Middle  of  Vermis  and  Pons. 

layer  contains  two  kinds  of  cells,  one  large  and  known  as  PurMnje's 
cells,  the  other  smaller  and  known  as  stellate  cells.  The  cells  of 
Purkinje  lie  the  more  deeply,  being,  in  fact,  practically  at  the 
boundary  of  the  molecular  and  granular  layers.  They  measure  40  x 
30  /*  (yvd  to  -yjjp  in.)  and  have  large  round  nuclei.     Each  cell  gives 


360 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


off  an  enormous  number  of  branching  dendrites,  which  run  up 
toward  the  surface  of  the  cerebellum  in  the  shape  of  a  bush.  Each 
little  branch  sends  off  from  the  side  small  buds,  which  are  called 
the  gemtmdes  or  thorns.  These  branching  dendrites  do  not  pass  up 
altogether  like  the  branches  of  a  round  bush,  but  are  flattened  like  a 
broom.  The  Purkinje  cells  give  off  from  their  base  a  neuraxon  which 
runs  down  into  the  white  matter  of  the  cerebellum  (Fig.  181,  P). 


Fig.  181. — The  Different  Constituent  Elements  op  the  Gray  Cortical  Layer  of  the 

Cerebellum. 

Lying  throughout  the  molecular  layer  are  the  stellate  cells,  which 
are  much  smaller  in  size,  and  which  also  give  off  a  number  of  den- 
drites (Fig.  181,  S).  Each  cell  has  also  its  axis  cylinder  (neuraxon) 
and  this  sends  off  collaterals  which  end  in  a  fine  basket-like  network 
which  surrounds  the  body  of  the  cells  of  Purkinje  (Fig.  181).  On 
this  account  they  are  sometimes  called  basket  cells.  There  are 
other  stellate-shaped  cells  in  the  molecular  layer  which  lie  more 
superficially,  and  do  not  have  this  particular  connection  with  the 
Purkinje  cells,  but  appear  to  belong  to  the  same  type. 

The  granular  layer  contains  a  large  number  of  very  small  gran- 
ular-like cells  that  Golgi  was  the  first  to  show  were  really  nerve 
cells.  They  are  only  about  5  <>.  {-^^ts  in-)  m  diameter,  and  they  have 
a  number  of  short  dendrites  which  end  in  clubbed  extremities. 
(Fig.  181,  G).     They  give  off  a  very  fine  axis-cylinder  process  (neu- 


AXAT0MY    AND    PHYSIOLOGY    OF    THE    BRAIX. 


361 


raxon)  which  rims  up  into  the  molecular  layer  and  there  divides  in 
a  T-shaped  fashion,  the  fibres  running  parallel  to  the  surface  of 
the  convolution  and  passing  in  between  the  branches  of  the  cells 
of  Purkinje.  There  are  besides  these  granular  cells  a  few  larger 
cells  with  axis  cylinders  that  divide  and  subdivide,  ending  in  a 
finely  ramifying  plexus.  These  are  of  the  type  known  as  the  cells 
of  Golgi.     They  are  found  in  other  parts  of  the  brain. 

The  nerve  fibres  of  the  cerebellar  cortex  are,  as  in  the  cerebrum, 
radiating  and  tangential.  The  tangential  fibres  lie  at  the  level  of 
the  Purinkje  cells,  among  the  processes  of  which  they  run.     Just 


molecular 
lawyer 


granule 
granule 


-  /-/  —       layer 


Fig.  182. —Schematic  Diagram  of  the  Relations  of  the  Cerebellar  Cells.  .!, 
Afferent  fibre  to  basket  (stellate)  cell;  B,  neuraxon  of  Purkinje  cell;  C,  afferent  fibre  to 
Purkinje  cell ;  D,  afferent  (mossy)  fibre  to  granule  cell. 

beneath  the  pia  is  a  thin  connective  or  neuroglia  tissue  membrane 
which  sends  radial  fibres  down  through  the  gray  matter,  affording 
it  a  support. 

It  will  be  seen  that  the  general  arrangement  of  the  cerebellar 
cortex  is  analogous  to  that  of  the  cerebrum.  Associative  and  re- 
ceptive cells  are  found  in  the  granular  and  molecular  layers,  and 
they  send  processes  forming  a  rich  network  around  Purkinje' s  cells, 
which  are  efferent  in  function  (Fig.  182).  The  comparatively 
small  number  of  the  large  cells  is  in  harmony  with  the  view  that 
the  cerebellum  is  an  organ  that  receives  and  adjusts  nerve  impulses 
for  co-ordinate  distribution.  All  parts  of  the  cerebellar  cortex  are 
anatomically  alike. 

The  white  matter  of  the  cerebellum  consists  of  nerve  fibres,  some 
of  which  go  to  form  the  peduncles.  Others  form  anterior  and  pos- 
terior commissures,  running  through  the  two  extremities  of  the 
vermis  and  connecting  ihe  hemispheres.  There  is  also  a  longi- 
tudinal commissure  in  the  vermis.  The  white  matter  around  the 
corpus  dentatum  is  called  they/- 


362  DISEASES    OF   THE    NERVOUS   SYSTEM. 


The  Projection"  System. 

Having  described  the  general  arrangement  of  the  different 
divisions  of  the  brain  and  the  collections  of  gray  matter  found  in 
them,  we  are  prepared  to  study  the  tracts  of  white  matter  which 
connect  the  different  parts. 

The  white  matter,  as  already  shown,  is  made  up  of: 

(  Short. 

1.  Association  fibres   -  Long. 

(  Commissural. 

2.  Projection  fibres. 

1.  The  association  fibres  of  the  cortex  have  been  already  de- 
scribed. 

2.  The  projection  fibres  are  those  which  connect  different  areas  of 
the  cortex  with  the  basal  ganglia  and  the  ganglionic  masses  of  the 
pons,  medulla,  and  spinal  cord.  Recent  researches  by  Flechsig  have 
led  him  to  assert  that  the  projection  fibres  are  much  less  numerous 
than  has  been  suspected,  and  that  they  come  only  from  the  central 
convolutions,  part  of  the  first  and  second  temporal,  part  of  the  oc- 
cipital lobe,  the  hippocampus,  uncus,  and  part  of  the  limbic  lobe. 
These  are  the  parts  of  the  brain  identified  with  the  function  of  vol- 
untary movement  and  general  and  tactile  sensation,  hearing,  sight, 
smell,  and  taste.  The  area  of  the  cortex  of  the  brain  thus  connected 
to  parts  below  by  projection  fibres  is  only  about  one-third  of  the 
whole.  The  remaining  two-thirds  of  the  brain  cortex  is  not  in 
direct  connection  with  parts  below,  but  is  closely  connected  with  the 
projection  centres  by  association  fibres.  Flechsig  considers  the 
parts  of  the  brain  which  are  thus  connected  by  association  fibres  as 
higher  centres,  identical  with  the  more  complex  mental  acts,  and 
he  calls  them  the  association  centres. 

The  association  centres  according  to  this  view  are  the  frontal 
lobes,  part  of  the  parietal  and  occipital  and  part  of  the  temporal  lobes. 
The  views  of  Flechsig  have  attracted  great  attention,  but  have  not 
yet  been  generally  adopted,  and  may  require  considerable  modifica- 
tion. 

The  projection  fibres  of  the  brain  form  the  different  pathways 
(a)  by  which  the  special  and  general  sensations  pass  up  to  the  brain 
cortex  and  (b)  by  which  the  voluntary,  automatic,  and  psycho-reflex 
movements  of  the  body  are  brought  about. 

(b)  The  Motor  Tracts. — The  cerebro-spinal  motor  paths  are 
of  two  kinds :  the  direct  or  voluntary  and  the  indirect  motor  tracts. 
The  direct  motor  tract  originates  from  cells  in  the  central  convolu- 
tions; the  neuraxons  of  these  cells  pass  down  and  are  gathered 
together  in  a  narrow  band  which  passes  through  and  occupies  nearly 
the  whole  of  the  posterior  segment  of  the  internal  capsule.  The 
fibres  continue  on  into  the  pons  Varolii  and  medulla,  and  at  the 
latter  point  give  off  some  terminals  which  cross  (except  those  for  the 
sixth  nerve)  to  the  nuclei  of  the  motor  cranial  nerves.     The  rest  of 


ANATOMY    AND    PHYSIOLOGY    OF    THE   BRAIN. 


363 


che  bundle  passes  on  through  the  medulla,  and  ninety  per  cent 
cross  over  at  its  lower  portion,  forming  there  the  anterior  pyra- 
mids. About  ten  per  cent  of  the  fibres  do  not  cross,  however,  but 
continue  on  the  same  side.  The  crossed  buudle  passes  into  the 
lateral  column  of  the  spinal  cord,  forming  the  crossed  pyramidal 
tract,  which  passes  on,  diminishing  in  size  as  far  as  the  sacral  part 
of  the  cord.     It  gives  off  terminal  end  brushes  which  surround  the 


'/cf4a7< 


Fig.  183.— Diagram  of  the  Direct  or  Fig.    184.— Diagram    of  the   Indi- 

Volcntary   Motor  Tract,  showing  the  rect  or  Involuntary  Motor  Tract. 

course  of  the  motor  impulses  from  tlin 
cerebral  cortex  to  the  voluntary  mus- 
cles (after  Van  Gehuchten). 

cells  of  the  anterior  horns.  The  small  uncrossed  band  of  fibres  con- 
tinues on  in  the  mesial  part  of  the  anterior  column,  forming  the 
direct  pyramidal  tract,  or  column  of  Ttlrck.  The  fibres  of  this 
tract  cross  over  in  the  anterior  commissure  at  different  levels,  and 
their  terminals  also  connect  with  the  motor  cells  of  the  anterior 
horns.  Thus  it  will  be  seen  that  the  direct  motor  tract  is  a  long 
continuous  strand  of  fibres,  composed  of  single  neurons  putting  the 
cortex  of  the  central  convolution  directly  in  contact  with  the  motor 
cells  of  the  pons,  medulla,  and  spinal  cord  of  the  opposite  side. 


3G4  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Each  pyramidal  tract,  as  it  reaches  the  spinal  cord,  contains  about 
eight}*  thousand  fibres  (Fig.  183). 

The  mdireei  mot&r  tract  arises  from  nerve  cells  in  the  anterior 
central  convolution,  and,  perhaps  to  some  extent  in  the  frontal 
lobe  adjoining.  Its  fibres  pass  down  into  the  internal  capsule, 
mingling  directly  with  those  of  the  direct  motor  tract  and  giving  off 
collaterals  to  the  optic  thalamus.  The  fibres  pass  through  the 
cerebral  peduncles,  occupying  their  inner  four-fifths,  or  motor  part, 
and,  finally,  reach  certain  deposits  of  nerve  cells  in  the  pons  Varolii 
known  as  the  pons  nuclei.  They  surround  these  cells  here  with 
terminal  end  brushes.  From  these  cells  neuraxons  cross  the  median 
line  in  the  middle  cerebellar  peduncle  and  thence  to  the  cortex  of 
the  cerebellum,  where  they  in  turn  end.  From  here  the  nerve  cells 
send  fibres  through  the  peduncles  by  paths  not  perfectly  well  known 
down  into  the  spinal  cord,  where  they  pass  along  mainly  in  the 
lateral  fundamental  columns,  to  connect  finally  with  the  anterior- 
horn  cells.  Thus  it  Avill  be  seen  that  the  indirect  motor  tract  is 
composed  of  («)  a  corticopontine  neuron,  (b)  a  pons-cerebellar 
neuron,  (c)  a  cerebello-spinal  neuron,  and  (d)  the  peripheral  motor 
neuron  (Fig.  184). 

The  direct  motor  tract  is  concerned  in  all  voluntary  movements, 
and  when  the  anterior-horn  cells  of  the  cord  are  cut  off  from  it  by 
disease  there  is  a  spastic  form  of  paralysis.  The  indirect  motor 
tract  is  concerned  in  the  co-ordination  of  bodily  movement  and  in  the 
higher  reflex  and  automatic  acts.  It  is  largely  through  these  in- 
direct tracts  that  the  skilled  automatic  movements  take  place. 
Playing  musical  instruments  and  the  involuntary  use  of  the  hands 
and  limbs  in  work  or  games  of  skill  are  under  the  control  of  this 
mechanism.  When  the  spinal  cord  is  cut  off  from  it,  there  is  an 
unsteady  and  disordered  gait  and  arm  movement.  The  course  of 
the  direct  and  indirect  motor  tracts  is  shown  in  the  accompanying 
diagrams. 

The  Sensory  Tracts. — The  next  important  pathways  in  the  brain 
and  cord  are  the  sensory,  and  they  are  concerned  in  bringing  tactile, 
muscular  and  general  sensations  from  the  remoter  parts  of  the  body 
to  the  cortex  of  the  brain.  It  will  be  easier  to  follow  these  tracts  if 
we  begin  at  the  periphery  and  follow  the  course  of  the  fibres  up  to 
their  centres  in  the  brain.  Just  as  in  the  case  of  motor  fibres,  we 
find  direct  and  indirect  tracts,  although  here  even  the  direct  sen- 
sory path  is  more  tortuous  and  broken  than  is  the  case  with  the 
motor  tracts. 

The  Direct  Sensory  Tract. — A  tactile  irritation  of  the  skin  passes 
up  the  sensory  nerve  to  a  posterior  spinal  ganglion,  where  the 
cell  body  from  which  the  fibre  is  derived  is  found.  It  passes  di- 
rectly through  the  ganglion,  enters  the  posterior  root  of  the  spinal 
cord,  and  passes  up  to  a  group  of  cells  lying  in  the  posterior  horns, 
where  it  mepts  and  surrounds  with  its  end  brush  a  second  sensory 
cell.  A  second  neuraxon  starts  from  the  body  of  this  cell ;  it  crosses 
over  through  the  anterior  commissure  of  the  spinal  cord  to  the 


AXATOMY    AND    PHYSIOLOGY    OF   THE    BRAIN. 


365 


lateral  column  of  the  other  side,  where  it  runs  up  in  the  antero- 
lateral ascending  tract,  reaches  the  medulla  and  pons,  and  passes 
through  this  until  it  comes  to  the  optic  thalamus.  Here  it  sends  its 
terminal  to  a  third  cell,  which  in  turn  sends  a  neuraxon  to  the  cortex 
of  the  central  convolutions.     Thus  the  cortical  centres  of  the  direct 


Fro.  186.—  The  Direct  Sensory  Tract, 
sliowinj?  the  arrangements  of  the  neurons 
(Van  Selrachtsff). 


Fig.  18(5.— The  Indirect  Sensory 
Tract. 


sensoiy  path  are  practically  the  same  as  the  motor  area  from  which 
the  motor  tract  started.  The  direct  sensory  tract  is  made  »p  of  (1) 
a  peripheral  sensory  neuron,  (_>  a  spinal-thalamic  neuron,  (3)  a 
thalamic-cortical  neuraxon  (see  Fdg.  185).* 

Tl,c  indirect  e&neary  trad  conveys  impulses  which  originate  in 
muscles,  joints,  and  the  viscera.      The  impulses  pass  up  sensory 

*  There  are  also  some  direct  sensory  impulses  which  go  from  the  posterior 
roots  to  the  columns  of  Goll  and  Burdach  and  thence  to  the  optic  thalami 
and  central  convolutions. 


366  DISEASES    OF   THE    NERVOUS    SYSTEM. 

nerves  through  the  .posterior  roots.  Some  now  pass  directly  into 
the  posterior  column  of  the  cord  of  the  same  side  and  ascend 
till  they  reach  the  upper  end,  where  their  end  brushes  surround  the 
cells  of  the  nuclei  of  the  column  of  Goll  and  of  Burdach.  From 
there  they  cross  over  to  the  other  side  in  the  sensory  decussation. 
Some  then  go  to  the  cortex  of  the  cerebellum,  where  they  terminate. 
The  cerebellar  cells  take  up  the  impulse  and  transmit  it  through  the 
superior  cerebellar  peduncles  *o  the  red  nuclei  and  optic  thalamus, 
where  they  terminate.  Another  neuron  now  carries  the  impulse  on 
to  the  central  convolutions.  Other  indirect  sensory  impulses  go 
from  the  sensory  roots  to  the  cells  of  the  column  of  Clark,  thence 
by  the  direct  cerebellar  tracts  to  the  cerebellum,  thence  to  the  red 
nuclei  and  thalamus,  and  finally  to  the  brain  cortex.  The  indirect 
sensory  tract  is  thus  composed  of  (1)  a  peripheral  sensory  neuron, 
(2)  a  spinal-cerebellar  neuron,  (3)  a  cerebellar-thalamic,  and  (4)  a 
thalamic-cortex  neuron.  The  direct  sensory  tracts  carry,  for  the 
most  part,  the  sense  of  touch,  pain,  and  temperature.  The  indirect 
sensory  tracts  are  concerned  with  the  sensation  from  the  muscles 
and  joints  which  have  to  do  with  co-ordination,  and  also  with  vis- 
ceral sensations.  It  is  through  the  indirect  sensory  and  indirect 
motor  tracts  that  the  automatic  and  psycho-reflex  acts  are  per- 
formed. 

Other  Projection  Systems. — The  optic,  acoustic,  and  olfactory 
projection  tracts  have  been  described  in  connection  with  their 
peripheral  nerves. 

The  Membranes  of  the  Brain. — The  membranes  of  the  brain 
are  the  dura  mater,  the  arachnoid,  and  pia  mater.  The  dura  mater 
lines  the  inner  surface  of  the  skull.  It  is  attached  loosely  to  the 
concavity,  but  closely  to  the  base.  It  splits  into  two  layers  to  form 
the  venous  sinuses  of  the  skull.  The  inner  of  the  two  layers  at  cer- 
tain points  projects  inward  to  form  membranous  septa.  These  are 
known  as  the  great  longitudinal  or  cerebral  falx,  the  lesser  longi- 
tudinal or  cerebellar  falx,  and  the  tentorium.  Hence  both  venous 
sinuses  and  membranous  septa  are  formed  out  of  the  inner  layer. 
The  outer  layer  forms  the  periosteum  of  the  bone.  The  dura  mater 
is  supplied  with  sensory  nerves,  chiefly  by  the  trigeminus  but  pos- 
teriorly by  the  vagus.     The  blood  supply  will  be  described  later. 

The  arachnoid  is  a  thin,  transparent,  fibrous,  non-vascular  mem- 
brane lying  between  the  pia  and  dura  and  continuous  with  the 
spinal  arachnoid.  It  bridges  over  the  fissures  and  the  depressions 
at  the  base  of  the  brain  and  forms  between  the  pia  and  itself  certain 
lacunae  or  spaces.  These  are  the  central  lacuna  found  at  the  begin- 
ning of  the  fissure  of  Sylvius,  the  callosal,  and  those  of  the  trans- 
verse fissures  and  of  the  lateral  aspect  of  the  pons  Varolii.  The 
space  between  the  dura  and  arachnoid  is  called  the  subdural  or 
arachnoid  cavity.  It  is  lined  with  epithelium  and  resembles  other 
serous  cavities.  The  inner  surface  of  the  arachnoid  is  connected 
with  the  pia  by  numerous  delicate  fibrous  processes.  The  space 
between  these  membranes  is  called  the  subarachnoid  space.     It  com- 


ANATOMY    AND    PHYSIOLOGY    OF   THE   BRAIN.  367 

municates  with  the  subdural  space  by  means  of  the  foramen  of 
Magendie,  which  lies  in  the  part  of  the  arachnoid  that  passes  over 
the  pons  and  medulla,  closing  in  the  fourth  ventricle.  The  subdural 
and  subarachnoid  spaces  contain  a  serous  fluid.  The  normal  amount 
ranges  from  two  drachms  to  two  ounces,  it  being  greater  in  old 
people.  The  arachnoid  contains  no  nerves  or  blood-vessels.  It  is 
described  by  some  as  a  part  of  the  pia  mater. 

The  pia  mater  lies  beneath  the  arachnoid  and  is  closely  applied 
to  the  brain  in  all  its  folds.  It  is  continuous  with  the  spinal  pia. 
It  is  very  vascular  and  supplies  the  whole  periphery  and  part  of  the 
interior  of  the  brain  with  blood.  It  consists  of  two  layers :  an 
outer  holding  the  larger  vessels,  and  an  inner  delicate  layer  closely 
associated  with  the  superficial  neuroglia  of  the  brain.  The.  pia 
mater  folds  upon  itself  and  passes  through  the  transverse  fissure 
into  the  third  and  lateral  ventricles  of  the  brain.  These  vascular 
folds  fcrm  the  velum  interpositum,  which  gives  off  a  choroid  plexus 
to  the  lateral  and  third  ventricles.  Another  fold,  the  inferior 
choroid  plexus,  is  given  off  to  the  fourth  ventricle.  The  pia  mater 
has  vasomotor,  but  no  sensory  nerves. 

Functions  of  the  Brain  Membrane. — The  dura  mater,  by  its 
outer  layer,  acts  as  a  periosteum;  by  its  inner  layer  as  a  lymph 
sac.  It  is  also,  by  virtue  of  its  sensitiveness,  a  protection  against 
injury  and  disease.  The  arachnoid  forms  the  inner  wall  of  the 
lymph  sac.  The  pia  mater  is  a  vascular  and  nutritive  organ.  It  is, 
however,  also  closely  connected  with  the  lymphatic  system  of  the 
arachnoid.  The  blood  supply  and  lymph  supply  of  the  brain  vary 
in  amount.  In  congestion  the  lymph  can  pass  into  the  spinal  canal 
or  be  rapidly  taken  up  by  the  absorbents.  In  anaemia  there  may 
be  compensatory  increase  of  lymph.  This  fluid  in  disease  may  ac- 
cumulate in  the  arachnoid  sac,  the  subarachnoid  space,  or  the 
ventricles,  these  spaces  being  all  in  communication  with  each  other. 

The  Blood  Supply  of  the  Brain  axd  its  Membranes. — - 
The  vascular  supply  of  the  scalp,  skull,  and  dura  mater  comes  from 
the  external  carotids ;  that  of  the  eye,  brain,  and  pia  mater  from  the 
internal  carotids  and  vertebrals.     The  arrangement  is  shown  here : 

f  Occipital,  inferior  meningeal,  arteries. 
Posterior  auricular. 

External  carotid  J  TenJporal  j  ^^ 

(  Posterior. 
Ascending  pharyngeal,  posterior  meningeal. 
Internal  maxillary,  middle  meningeal,  small  meningeal. 
'  Anterior  meningeal. 
Internal  carotid  j  Anterior  cerebral, 
gives  off  1  Middle  cerebral. 

°  Posterior  communicating. 

_  Anterior  choroid, 
f  j  Posterior  meningeal. 
Vertebral    and  J     <  I'^rior  cerebellar, 
i .•! ; re  -    Anterior  cerebellar. 


gives  off 


basilar  give  off 


Anterior  cerebellar. 
Superior  cerebellar. 
Posterior  cerebral. 


368 


DISEASES    OF   THE    XEEVOUS    SYSTEM. 


The  general  arrangement  and  distribution  of  the  arteries  of  the 
scalp  and  dura  are  shown  in  the  accompanying  diagram  (Fig.  187). 

The  blood  supply  of  the  meninges  comes  from  the  anterior,  middle, 
and  posterior  meningeal  arteries.  These  all  come,  except  the  small 
anterior  meningeal  branches  and  a  small  posterior  branch,  from  the 
external  carotid.  The  blood  passes  into  the  diploic  veins,  and  from 
there  passes  chiefly  into  the  lower  occipital  and  lateral  sinuses. 


Fig.  187.— Showing  the  Blood  Supply  op  thi  Scalp  and  that  of  the  Dura 
Mater  by  the  Middle  Meningeal. 


Some  of  it,  however,  returns  in  the  venae  comites.  It  all  returns 
down  toward  the  base  of  the  skull.  The  most  important  of  the 
arteries  is  the  middle  meningeal,  both  on  account  of  its  size  and  its 
distribution  above  important  functional  areas. 

The  blood  supply  to  the  pia,  mater  and  bra <in substance  comes  from 
the  internal  carotid  and  the  vertebral  arteries.  The  branches  of  the 
former  artery  give  off  the  anterior  and  middle  cerebral,  the  pos- 
terior communicating,  and  anterior  choroid.  The  vertebral  arteries 
give  off  the  inferior  cerebellar,  while  the  basilar  branch  of  the  ver- 
tebrals  gives  off  the  transverse,  anterior  cerebellar,  superior  cere- 
bellar, and  posterior  cerebral  arteries. 


ANATOMY   AND    PHYSIOLOGY   OF   THE    BRAIN. 


369 


The  cerebral  arteries,  anterior,  middle,  and  posterior,  are  the 
three  largest  and  most  important.  By  their  anastomoses  the  circle 
of  Willis  is  formed  (Fig.  188).  From  the  circle  of  Willis  and  the 
beginnings  of  the  three  arteries  mentioned,  several  groups  of  vessels, 
six  m  all,  are  given  off.     They  enter  the  base  of  the  brain  and  supply 


Fio.  188.—  Shovtcno  the  Arteries  at  the  Base  op  the  Brain.     On  the  right  side  the 
brain  is  cut  awa)-,  showing  the  cerebral  arteries  and  the  course  of  the  posterior  cerebral. 

the  great  basal  ganglia  and  adjacent  white  matter.  They  are  called 
the  central  arteries,  and  they  are  the  vessels  usually  affected  in  cere- 
bral hemorrhages  of  adult  life.  They  do  not  anastomose  with  each 
other.  The  cortical  arteries  are  the  terminal  branches  of  the  great 
cerebral  arteries.  They  anastomose  with  each  other  but  slightly. 
They  are  distributed  very  widely  and  carry  much  more  blood  than 
the  central  groups.  Their  distribution  is  shown  in  Fig.  189.  The 
cortical  arteries  are  distributed  in  the  pia.  and  from  there  they  pass 
24 


370 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


in  two  sets,  a  superficial  and  a  deep,  into  the  gray  matter,  and  for 
a  short  distance  into  the  white  matter.  They  pass  straight  in  at 
right  angles  to  the  surface.  They  have  richly  arborescent  branches 
which  do  not  anastomose;  consequently  a  knife  plunged  straight 
into  the  brain  does  not  cut  many  vessels.  The  cortical  arteries 
probably  anastomose  somewhat  with  each  other,  though  not  very 
freely.  There  is  slight  if  any  anastomosis  between  the  cortical  and 
central  arteries.  The  pressure  is  thought  to  be  less  in  the  vessels 
of  the  gray  matter. 

The  capillaries   are   surrounded  by  spaces   called  perivascular 
spaces  which  serve  as  lymphatic  channels.     The  neuroglia  cells  send 


Fig.  189.— Showing  the  Distribution  of  the  Artery  of  the  Sylvian  Fissure,  a 
Prolongation  of  the  Middle  Cerebral.  The  area  in  front  of  the  shaded  part  is  sup- 
plied by  the  anterior  cerebral,  that  behind  by  the  posterior  cerebral. 


processes  which  connect  with  or  form  passages  to  the  vessel  walla 
(Fig.  190).  The  blood-vessels  of  the  brain  have  probably  vaso- 
motor nerves,  though  this  is  denied  by  some. 

The  blood  of  the  convex  and  mesial  cerebral  surface,  flowing  up 
from  the  base,  leaves  the  capillaries  and  enters  veins.  Thence  it 
still  passes  upward,  and  for  the  most  part  enters  the  longitudinal 
sinus.  The  most  of  the  vessels  enter  the  posterior  portion  of  the 
sinus  and  in  a  direction  forward  and  upward,  i.e.,  against  the  cur- 
rent in  the  sinus.  The  course  of  the  blood  current  is,  therefore, 
opposed  both  to  gravitation  and  to  the  venous  flow. 

The  veins  of  the  cerebrum  are:  1,  the  superficial  cerebral ;  2,  the 
deep  cerebral  veins ;  and,  3,  the  cerebral  sinuses.  The  superficial 
cerebral  veins  are  venee  comites.  Those  on  the  convex  and  mesial 
surfaces  empty  chiefly  into  the  superior  longitudinal  sinus,  as  de- 
scribed; those  on  the  basal  surface  empty  into  the  cavernous  and 
lateral  sinuses.     These  veins  have  no  valves,  and  their  walls  are 


ANATOMY   AND   PHYSIOLOGY    OF   THE    BKAIX.  371 

very  thin  and  without  muscular  fibres.  The  deep  cerebral  veins,  or 
venae  Galeni,  receive  the  blood  from  the  lateral  ventricles  and  from 
some  of  the  central  arteries  supplying  the  basal  ganglia.  They 
envpty  into  the  straight  sinus. 

The  cerebral  sinuses  are  fifteen  in  number.  The  important  ones 
are  the  superior  and  inferior  longitudinal,  the  straight,  the  lateral, 
the  occipital,  the  cavernous,  and  the  superior  and  inferior  petrosal. 
They  carry  blood  for  the  most  part  in  a  direction  from  before  back- 
ward, and  convey  it  eventually  to  the  internal  jugular. 

Most  of  the  blood  of  the  convexity  and  mesial  surface  must  pass 
into  the  longitudinal  sinus,  but  there  is  a  slight  connection  of  some 


Fig.  190.  —  Showing  the  Neuroglia  Cells  op  the  Brain,  their  Relations  to  the 
Blood- Vessels;  also  the  Sustentacular  Processes  op  the  Epithelial  Cells  of  the 
Lateral  Ventricle  (Marehi).  A,  Epithelial  cells  lining  lateral  ventricle;  a,  process  of 
same;  6,  spider  or  neuroglia  cell;  c,  blood-vessel. 

of  the  veins  with  the  superior  petrosal  and  straight  sinuses.  The 
superior  longitudinal  sinus  also  communicates  slightly  with  veins  of 
the  scalp  and  with  the  facial  vein.  Some  of  the  blood  from  the 
mesial  surface  also  goes  to  the  veins  of  Galen. 

On  the  whole,  however,  the  system  of  the  convex  and  mesial 
cerebral  surface  is  a  close  corporation,  the  blood  having  to  pass  into 
the  superior  longitudinal  sinus  and  torcular  Herophili,  where  it 
meets  that  of  the  straight  and  occipital  sinuses,  and  flows  forward 
through  the  lateral  sinuses  to  the  internal  jugular.  The  circulation 
of  the  basal  surface  is  less  isolated.  All  the  basal  sinuses  com- 
municate with  each  other  freely,  and  there  are  slight  communica- 
tions between  the  veins  of  the  scalp  and  the  cavernous,  lateral,  and 
inferior  petrosal  sinuses.  It  is  safe  to  tie  any  of  the  sinuses,  except 
the  lateral  and  the  posterior  part  of  the  longitudinal.  The,  cere- 
bellar veins,  superior,  inferior,  and  lateral,  empty  into  the  straight, 


372  DISEASES   OF   THE    NERVOUS   SYSTEM. 

the  lateral,  and  superior  pertrosal  sinuses.  None  of  the  cerebral 
veins  or  sinuses  have  valves. 

The  pressure  in  the  internal  carotid  arteries  is  about  150  mm., 
that  in  the  cerebral  sinuses  70  to  80  mm.  (G-erhardt),  and  that  in 
the  jugular  veins  is  almost  negative.  Both  arteries  and  veins  are 
more  delicate  than  the  extracerebral  vessels. 

Except  in  gray  matter,  the  brain  is  not  a  very  vascular  organ, 
but  this  gray  tissue  ranks  in  richness  of  blood  supply  with  the  lungs 
and  liver.  The  amount  of  blood  in  the  brain  at  any  one  time  is 
only  about  one  to  two  per  cent  of  the  total  blood  in  the  circulation, 
or  about  four  ounces  (Ranke). 

The  diameter  of  the  common  carotids  is  6.7  mm.  (Thorne), 
that  of  the  subclavians  6.2  mm.,  that  of  the  internal  carotids  4 
mm.,  and  that  of  the  vertebrals  3.55  mm.  (Gerhardt).* 

The  Functions  of  the  Brain — Cerebral  Localization. — ■ 
The  brain  is  the  seat  of  conscious  intelligence  and  mental  activity. 
It  has  also  control  and  direction  of  voluntary  movements,  it  is  the 
seat  of  instinctive  acts,  and  it  regulates  in  a  measure  the  vasomotor, 
trophic,  and  secretory  mechanisms  of  the  body. 

The  Prefrontal  Lobes. — The  prefrontal  lobes,  or  that  part  of 
the  brain  in  front  of  the  precentral  convolution,  are  concerned 
with  volition  and  the  power  of  self-control,  concentration  of  thought 
and  attention  (Ferrier).  They  form  one  of  the  higher  or  associa- 
tion centres.  The  posterior  part  contains  centres  for  the  move- 
ments of  the  head  and  eyes.  Injuries  in  this  part  of  the  brain 
produce  changes  of  character,  indicated  by  peevish aess  and  irrita- 
bility of  temper,  mental  enfeeblement,  lack  of  power  to  concentrate 
the  mind  or  to  control  the  acts  or  emotions. 

Tlie  Central  Convolutions. — This  part  of  the  brain  is  called  the 
sensori-motor  area,  because  it  is  concerned  in  the  production  of  ner- 
vous impulses  which  cause  voluntary  motions  of  the  body.  Certain 
parts  of  this  area  are  in  relation  with  certain  groups  of  voluntary 
muscles  on  the  opposite  side  of  the  body.  These  areas  preside  not  so 
much  over  single  muscles  as  over  those  groups  of  muscles  which  act 
together  in  producing  definite  purposeful  acts.  The  lower  part  of  the 
central  convolutions,  known  as  the  central  operculum,  is  a  centre 
for  movements  of  the  larynx,  mouth,  tongue,  and  face.  Above  this 
area  and  about  the  middle  third  of  the  central  convolutions  is  the 
centre  for  the  movements  of  the  shoulder,  arm,  hand,  and  fingers. 
Still  farther  up,  near  the  longitudinal  fissure,  and  extending  over 
into  the  mesial  surface  and  back  into  the  superior  parietal  lobule,  is 
the  area  for  the  trunk,  hips,  legs,  feet,  and  toes.     The  base  of  the 

*J.    Crichton  Brown  gives  the  last  two  diameters  2.8  and  2.2  mm.  re- 
spectively. » 


AXATOMT   AXD    PHYSIOLOGY    OF   THE    BRAIX.  373 

first  and  second  frontal  convolutions  is  the  centre  for  movements  of 
the  head  and  eyes.  The  exact  arrangement  of  these  centres,  which 
have  been  determined  by  experiments  upon  monkeys  and  other  lower 
animals  as  well  as  by  clinical  and  surgical  observations  on  man,  is 
shown  in  the  accompanying  Figs.  191,  192.  The  motor  area  is  also 
the  centre  for  the  cutaneous  sensations  of  the  parts  corresponding  to 
the  muscular  groups  which  it  supplies,  so  that  what  is  called  the 
motor  is  really  a  sensori-motor  area.  The  motor  area,  when  irri- 
tated by  disease,  produces  paresthesia?  and  convulsive  movements 
in  the  groups  of  muscles  which  it  represents.  Destruction  of  it 
causes  not  only  a  paralysis,  but  a  certain  amount  of  cutaneous 
anaesthesia. 

The  various  sensori-motor  centres  are  not  sharply  limited,  but 
lap  one  over  the  other,  so  that  the  motor  area  for  the  forearm,  for 
example,  extends  over  somewhat  into  that  for  the  shoulder.  The 
corresponding  sensory  areas  are  more  diffuse,  so  that  it  takes  a  much 
more  extensive  destruction  of  a  certain  area  of  the  motor  cortex  to 
produce  an  anaesthesia  of  the  arm  than  it  does  to  produce  a  paraly- 
sis of  the  arm. 

The  sensori-motor  area  including  some  adjacent  parts  is  called  by 
Flechsig  the  "  somatosphere, "  because  here  he  thinks  are  received 
the  afferent  impulses  of  general  (visceral)  as  well  as  special  tactile 
and  muscular  sensations  from  all  over  the  body. 

Bilateral  Representation. — Those  muscles  of  the  two  siiles  of  the 
body  which  act  together  have  a  double  representation  in  the  brain. 
For  example,  each  group  of  muscles  used  in  inspiration  has  a  centre 
in  both  hemispheres;  consequently,  when  one  centre  is  destroyed 
no  paralysis  results,  for  the  reason  that  the  other  centre  continues 
its  work.  In  the  same  way  some  of  the  muscles  of  the  face,  such 
as  those  for  closing  the  eyes,  have  a  double  representation,  and  a 
lesion  destroying  the  centre  for  the  orbicularis  palpebrarum  on  one 
Bide  will  not  usually  cause  paralysis,  because  of  the  continued  action 
of  the  centre  of  the  other  side.  The  more  perfect  and  habitual  the 
associated  action  of  the  muscles  of  the  two  sides  of  the  body,  the 
more  completely  can  one  centre  do  the  work  of  its  associate.  The 
best  examples  of  the  muscles  having  the  double  representation  are 
the  orbicularis  palpebrarum,  the  muscles  of  the  vocal  cords,  the 
muscles  concerned  in  deglutition  and  in  respiration.  The  muscles 
of  the  viscera  and  blood-vessels  have  no  known  representation  in  the 
cortex  of  the  human  brain. 

The  special  sensations  have  a  bilateral  representation  also;  but 
the  more  specialized  the  sense  the  less  can  one  hemisphere  take 
the  place  of  the  other. 


374 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


Occipital,  Parietal,  and  Temporal  Lobes — Centres  of  Special 
Sense. — The  special  senses  have  two  centres — the  primary  and  the 
secondary.  The  primary  centres  are  connected  with  the  ganglia  at 
the  base  of  the  brain ;  the  secondary  centres  are  situated  in  the  cortex. 


The  primary  centre  for  vision  is  in  the  posterior  part  of  the  optic 
thalamus,  the  external  geniculate  body,  and  anterior  corpora  quadri- 
gemina.  The  secondary  centre  is  situated  in  the  occipital  lobe,  and 
particularly  upou  its  mesial  surface  and  in  that  of  the  cuneus, 
known  as  the  calcarine  fissure.  Each  occipital  lobe  is  the  centre  for 
visual  impulses  from  the  corresponding  half  of  the  retina  of  each 
eye ;  for  example,  the  left  occipital  lobe  is  the  centre  for  vision  of 


AXATOMY    AXD    PHYSIOLOGY    OF   THE    BRAIX. 


375 


the  left  half  of  the  retina  of  each  eye.  This  relation  is  shown  in 
the  diagram  (see  Optic  Nerve).  Total  destruction  of  both  occipital 
lobes,  or  even  of  a  considerable  part  of  thern  if  the  destruction  in- 


^  M  ft 


s 


volves  the  median  surface,  will  cause  blindness.     Destruction  of 
one  lobe  causes  only  half-blindness  or  hemianopsia. 

The  primary  centre  for  hearing  is  in  the  posterior  tubercle  of  the 
corpora  quadrigemina  and  the  internal  geniculate  body.  The  secon- 
dary centre  is  in  the  cortex  of  the  first  and  second  convolutions  of 


376  DISEASES   OF   THE    NERVOUS    SYSTEM. 

the  temporal  lobe.  Destruction  of  one  temporal  lobe  causes  deafness 
in  the  opposite  ear.  This  deafness,  however,  is  not  complete  be- 
cause the  sense  of  hearing  has  a  bilateral  representation ;  each  ear, 
in  other  words,  sends  fibres  to  the  temporal  lobes  of  each  side,  al- 
though more  fibres  cross  over  than  go  to  the  lobe  of  the  correspond- 
ing side.  The  consequence  is  that  the  loss  of  one  temporal  lobe  is 
in  a  measure  supplied  by  the  other  (vide  Aphasia). 

The  primary  centre  for  smell  is  in  the  olfactory  lobes.  The 
secondary  centre  is  probably  in  the  anterior  part  of  the  limbic  lobe, 
the  uncus  and  in  part  of  the  hippocampal  convolution.  Whether 
the  tracts  for  the  sense  of  smell  are  connected  with  the  optic  thala- 
mus or  other  ganglia  is  not  definitely  known. 

The  primary  centre  for  taste  is  not  known,  but  sensations  of 
taste  may  connect  with  the  optic  thalamus  before  passing  into  the 
secondary  centre,  which  is  in  the  hippocampal  convolution. 

Centres  for  Memories. — There  are  certain  classes  of  sensations 
and  perceptions,  simple  in  character  and  frequently  repeated,  so 
that  they  finally  get  to  be  used  almost  automatically  in  their  work. 
These  impressions  relate  to  the  use  of  the  muscles  in  speech,  in 
writing,  and  in  gesture  language ;  also  to  other  frequently  repeated 
purposeful  movements  of  the  limbs.  The  muscular  movements  in 
writing  and  speaking  are  so  often  repeated  that  certain  areas  in  the 
cortex  are  set  apart  for  the  memories  of  these  processes,  memory 
being  simply  a  revival  of  previously  registered  impressions.  The 
visual  sensations  and  the  ideas  elaborated  from  them,  which  are 
frequently  repeated  in  learning  to  read,  have  also  a  centre  which  is 
set  apart  for  them.  This  forms  a  centre  for  the  visual  memories  of 
language.  In  the  same  way  there  are  auditory  sensations  and  ideas 
elaborated  and  so  frequently  repeated  as  to  be  used  automatically  in 
acquiring  language.  These  are  stored  up  as  auditory  memories. 
We  have  what  may  be  called  motor  memories  connected  with  speech 
and  gesture.  These  special  memories  have  been  found  to  have  a 
certain  localization  in  the  brain.  The  centre  for  the  memories  of 
the  articular  movements  of  speech  is  in  the  posterior  part  of  the 
third  left  frontal  convolution ;  the  centre  for  the  memories  of  the 
movements  of  writing  is  not  perfectly  well  known,  but  is  thought 
to  be  at  the  posterior  part  of  the  second  left  frontal  convolution. 
The  centre  for  the  memories  of  gesture  language  is  unknown.  The 
centre  for  the  memories  of  ordinary  co-ordinate  movements  is  prob- 
ably in  the  inferior  parietal  lobule.  The  centre  for  the  visual 
memories  of  written  language  is  in  the  angular  gyrus,  extending 
backward  from  there  into  the  occipital  lobe.  The  centre  for  the 
auditory  memories  of  spoken  language  is  in  the  posterior  part  of  the 


ANATOMY   AND    PHYSIOLOGY    OF   THE    BKAIN,  377 

first  and  the  corresponding  upper  part  of  the  second  temporal  con- 
volution. In  right-handed  people  all  the  memory  centres  are  in  the 
left  cerebral  hemisphere;  in  left-handed  people  they  are  in  the  right 
hemisphere.  The  destruction  of  these  memory  centres  produces 
different  forms  of  aphasia,  as  will  be  described  later.  In  addition 
to  that,  disturbances  in  these  centres  are  produced  by  lesions  which 
cut  off  the  associating  fibres  connecting  these  centres  with  each 
other  or  with  motor  or  sensoiy  centres  proper. 

The  Centrum  Ovale,  Corpus  Callosum,  and  the  Associative  Filia- 
tions of  the  Brain. — The  different  parts  and  centres  of  the  brain  are 
connected  together  by  the  associating  tracts  and  with  lower  levels 
by  the  projection  fibres.  The  simpler  and  less  developed  centres  of 
the  two  halves  of  the  brain  are  closely  connected  by  fibres  that  run 
chiefly  in  the  corpus  callosum.  The  more  highly  specialized  and 
less  simple  in  function  a  centre,  the  less  close  is  its  commissural 
connection  and  the  more  independent  is  one  half  of  the  brain  from 
the  other.  Thus  the  centres  for  the  movements  of  the  thorax  in 
respiration  are  closely  bound  with  each  other;  those  for  the  pur- 
poseful movements  of  the  hands  less  so;  those  for  receiving  visual 
impressions  are  almost  independent;  and  the  centres  for  the  mem- 
ories, which  are  still  more  highly  specialized,  are  practically  en- 
tirely independent.  We  inter  that  the  higher  mental  functions, 
therefore,  work  either  in  one  cerebral  hemisphere  or  in  the  other, 
and  that  the  two  halves  of  the  brain  do  not  co-operate  with  each 
other  in  much  of  the  higher  intellectual  work. 

The  corpus  callosum  is  the  great  commissural  tract  connecting 
the  two  cerebral  hemis}  heres  and  their  respective  centres.  The 
anterior  commissure  doe-?  some  of  the  same  work,  being  more 
specially  connected  with  the  function  of  olfaction.  The  posterior 
commissure  has  comparatively  few  bilateral  connecting  fibres,  its 
function  being  more  to  connect  the  thalamus  with  the  cranial  nerve 
nuclei  and  other  centres  below. 

The  Corpus  Striatum. — This  ganglion  is  inclose  relation  with 
the  cerebellum  and  with  nuclei  in  the  pons.  It  is  also  in  connection 
with  fibres  that  come  up  from  the  muscle-sense  tract,  in  the  spinal 
cord.  Its  functions  are  therefore  probably  connected  with  securing 
co-ordinate  and  purposeful  movements.  Destruction,  however,  of 
this  ganglion  in  the  human  brain  produces  no  definite  symptoms, 
and  local  lesions  of  it  cannot  be  diagnosticated.  It  is  therefore 
called  clinically  a  Intent  region. 

The  Thalamus  Opticus. — The  thalamus  is  in  relation  by  its  pro- 
jection fibres  with  the  frontal,  parietal,  occipital,  and  temporal 
cortex.     The  fibres  that  go  to  the  occipital    cortex  are  connected 


378  DISEASES    OF   THE    NERVOUS    SYSTEM. 

with  the  optic  tract,  and  have  to  do  with  the  function  of  vision. 
The  fibres  that  go  to  the  temporal  lobe  are  connected  with  the  audi- 
tory tract,  and  have  to  do  with  the  function  of  hearing.  The  optic 
thalami  seem  to  have  some  relation  to  the  expression  of  emotions. 
In  cerebral  paralyses  in  which  they  are  involved  the  patient  cannot 
involuntarily  express  joy,  grief,  etc.  Lesions  of  the  posterior  part 
of  the  thalamus  will  produce  partial  blindness.  Other  than  this, 
lesions  of  the  optic  thalamus  produce  no  definite  symptoms  which 
enable  us  to  make  a  local  diagnosis.  Disturbances  of  hearing  have 
not  certainly  been  traced  to  lesions  in  the  thalamus.  It  is  probably 
a  primary  centre  for  sensations  of  touch,  muscular  sense,  and  per- 
haps for  smell  and  taste,  but  no  definite  facts  in  human  pathology 
have  as  yet  satisfactorily  proved  this.  Lesions  of  the  thalamus 
sometimes  produce  various  forms  of  mobile  spasm,  but  these  are 
generally  attributed  to  irritation  of  the  fibres  of  the  internal  cap- 
sule, which  go  close  to  it.  Hence,  aside  from  disturbances  of  vision, 
the  optic  thalamus  also  must  be  considered  clinically  a  latent 
region. 

The  Corpora  Quadrigemina. — The  anterior  tubercles  of  the  cor- 
pora quadrigemina,  together  with  the  external  geniculate  bodies, 
form  part  of  the  primary  centres  of  vision.  The  anterior  tubercles, 
however,  have  to  do  chiefly  with  reflex  movements  of  the  pupil 
and  the  ciliary  muscles.  The  posterior  tubercles  of  the  corpora 
quadrigemina  and  the  internal  geniculate  body  are  connected  with 
the  auditory  nerve,  and  have  to  do  with  reflex  movements  associated 
with  hearing  and  space  sensations.  They  also  appear  to  receive 
some  fibres  from  the  cerebellum ;  their  injury  or  disease  produces 
some  disturbances  in  equilibrium  and  possibly  in  hearing.  Owing 
to  the  fact  tha/t  the  nuclei  of  the  third  nerves  and  the  red  nuclei  lie 
beneath  the  corpora  quadrigemina,  lesions  of  these  latter  produce 
irritations  and  paralyses  of  the  third  nerve,  disturbances  in  equilib- 
rium, and  forced  movements.  Lesions  in  this  neighborhood  some- 
times cause  somnolent  and  stuporous  states. 

The  red  nuclei  are  connected  with  the  anterior  cerebellar 
peduncles  on  the  one  hand  and  with  the  lenticular  nucleus  and  optic 
thalamus  on  the  other,  and  are  concerned  in  securing  equilibrium 
and  the  adjustment  of  the  body  in  space. 

The  Cerebellum. — The  cerebellum  is  connected  with  the  pons, 
the  cerebrum,  and  spinal  cord.  It  sends  impulses  down  into  the 
antero-lateral  columns  of  the  cord,  and  through  the  anterior 
peduncles  to  the  red  nuclei,  the  thalamus,  corpora  striata,  and  the 
central  convolutions.  It  receives  impulses  from  the  cortex  of  the 
frontal  lobes,  which  go  down  into  the  pons,  connect  with  nuclei 


ANATOMY   AND    PHYSIOLOGY   OF   THE   BRAIN.  379 

there,  and  thence  pass  up  into  its  hemispheres  (indirect  motor 
tract) .  It  also  receives  impulses  from  the  spinal  cord,  through  its 
peduncles,  which  go  on  to  the  thalami  and  brain  cortex  (indirect 
sensory  tract).  There  is  therefore  a  nervous  circuit  between  the 
cerebrum,  brain  axis,  cerebellum,  and  spinal  cord.  The  cerebellum 
has  thus  the  function  of  securing  the  higher  automatic  and  pyscho- 
reflex  movements,  and  through  its  further  relations  with  the  space- 
sense  nerve  (eighth)  of  enabling  us  to  keep  our  equilibrium  and 
maintain  our  relations  in  space.  The  vermis  or  median  lobe  is  the 
part  which  in  man  is  most  important  in  doing  this  work.  Lesions 
of  the  lateral  lobes  or  hemispheres  produce  few  direct  symptoms, 
and  they  are  called  latent  regions.  Injuries  of  the  median  lobe, 
however,  produce  disturbances  in  equilibrium,  forced  movements, 
and  a  peculiar  form  of  inco-ordination  in  gait  which  is  known  as 
cerebellar  ataxia.  Lesions  of  the  middle  peduncles  produce  forced 
movements  also,  the  forced  movements  being  either  toward  or  away 
from  the  side  of  the  lesion,  according  as  it  is  an  irritating  one  or  a 
destructive  one. 

The  pons  Varolii  contains  some  of  the  cranial  nerve  nuclei  and 
collections  of  nerve  cells  which  are  connected  with  fibres  from  the 
cerebral  cortex  on  the  one  hand  and  the  cerebellum  on  the  other. 
It  also  contains  the  long  tracts  of  nerve  fibres  that  pass  from  the 
cerebrum  down  through  into  the  medulla  and  spinal  cord  and  trans- 
verse tracts  of  fibres  which  connect  the  two  hemispheres  of  the  cere- 
bellum. Lesions  in  it  cause  disturbances  in  function  of  the  cranial 
nerves  and  of  the  motor,  sensory,  and  commissural  tracts. 

The  medulla  oblongata  contains  centres  of  the  cranial  nerves, 
and  in  it  also  are  various  reflex  and  automatic  centres  controlling 
and  regulating  the  vasomotor  system,  respiratory  and  cardiac  rhythm, 
visceral  movements  and  secretion. 

The  olivary  bodies  are  connected  with  the  cerebellum,  basal 
ganglia,  and  with  the  spinal  cord.  When  injured,  disturbances  of 
equilibrium  and  co-ordination  occur. 

The  Latent  Regions  of  the  Brain. — There  are  certain  parts  of 
the  cerebral  cortex  destruction  of  which  and  irritation  of  which  pro- 
duce no  special  and  distinctive  phenomena  in  man.  These  are  the 
greater  part  of  the  temporal  lobe  of  the  right  side  and  a  portion  of 
the  temporal  lobe  on  the  left  side.  A  part  of  the  inferior  parietal 
lobule  also  may  be  regarded  as  a  latent  region.  The  frontal  lobe 
we  have  already  spoken  of  as  being  concerned  with  certain  mental 
functions,  but  lesions  here  often  produce  no  symptoms,  and  may  be 
to  a  certain  extent  regarded  as  latent.  These  latent  regions  are 
called  by  Flechsig  the  higher  or  associative  centres.     The  corpora 


380  DISEASES   OF   THE   NERVOUS   SYSTEM. 

striata,  optic  thalami,  portions  of  the  centrum  ovale,  and  the  two 
lateral  hemispheres  of  the  cerebellum  are  latent  areas. 

Bkaust  Weight. — The  average  weight  of  the  male  brain  is 
1,358  gm. ;  that  of  the  female,  1,235  gm.  The  weight  varies  with 
age,  sex,  race,  and  intelligence,  and  with  a  number  of  other  factors. 
The  average  weight  of  the  brain  at  birth  is  327.8  gm. ;  the  brain 
grows  rapidly  until  the  age  of  four,  then  more  slowly  until  the  age 
of  seven,  then  very  slowly  up  to  the  age  of  sixteen  to  twenty.  At 
about  the  age  of  forty-five  in  man  and  fifty  in  woman  it  begins  to 
lose  weight  slowly,  and  at  the  age  of  eighty  or  over  it  has  lost  about 
120  gm.  (4  oz).  The  brain  of  man  weighs  absolutely  about  nine 
per  cent  more  than  that  of  woman,  Relatively  to  the  body  weight, 
the  brain  weight  of  man  is  about  2  per  cent;  that  of  Avoman  a  very 
little  less.     The  sexual  difference  is  extremely  small.* 

The  brain  weighs  more  in  the  civilized  races,  and  more  in  cer- 
tain of  the  civilized  races  than  others ;  the  brains  of  English,  Ger- 
man, and  Scotch  weigh  more  than  those  of  French,  Italian,  and 
Russian.  Some  of  the  African  and  Australian  tribes  have  the 
smallest  brain,  the  average  negro  brain  weighing  1,250  gm.  When 
a  brain  weighs  less  than  1,130  gm.  in  man  or  990  gm.  in  woman,  it 
is  called  a  microcephalic-  brain;  if  the  weight  is  above  1,490  gm.  in 
man  or  1,345  gm.  in  woman,  it  is  called  a  megalocephalic  brain. 

Brain  weight  has  a  certain  relation  to  intelligence,  which  is  not, 
however,  an  absolute  one.  Among  a  hundred  men  of  more  than 
average  intelligence,  the  percentage  of  large  brains  would  be  about 
2,"),  whereas  the  percentage  of  large  brains  among  persons  of  ordi- 
nary or  low  intelligence  would  be  not  more  than  4  or  5.  In  estimat- 
ing the  importance  of  brain  weight,  one  must  consider  the  height, 
the  weight  or  volume  of  body,  muscular  mass,  and  superficial  area; 
these  are  called  the  somatic  factors.  The  following  formula  has 
been  devised  by  Snell  for  estimating  the  mental  power  of  different 
animals  • 

*=£ 

In  this  formula  P  represents  the  psychical  factor  or  the  amount 
of  intelligence,  H  the  brain  weight,  K  the  body  weight,  S  the 
somatic,  factor.  The  somatic  factor  has  been  estimated  to  be  for 
mammals  about  0.666.  Applying  this  formula,  we  find  that,  ex- 
pressed relatively,  the  intelligence  of  man  equals  0.87;  woman, 
0.86;  the  ape,  0.42;  the  rabbit,  0.59;  the  birds  from  0.167  to  0.09. 

The  relative  weight  of  different  parts  of  the  brain  is  about  as 
follows:  frontal  lobes,  28  per  cent;  parietal  lobes,  36  per  cent; 
occipital,  10  per  cent;  temporal,  13  per  cent;  lobus  caudicus  or 
island  of  lieil,  9  per  cent;  pons,  14-  per  cent.  The  cerebellum 
weighs  about  one-eighth  as  much  as  the  cerebrum.  The  proportion 
of  the  gray  to  the  white  matter  in  adults  is  60  to  40  (Vierordt). 

*J.  C.  Brown  finds  that  after  making  all  allowances,  woman's  brain 
weighs  about  one  ounce  less  than  man's. 


ANATOMY    AND    PHYSIOLOGY    OF   THE   BRAIN. 


381 


The  depth  of  the  primary  fissures  is  not  quite  an  inch  (20  to  23 
mm.). 

There  are  from  one  thousand  two  hundred  to  two  thousand  million 
cells  in  the  cerebrum,  and  about  ten  million  large  cells  in  the  cere- 
bellum (Meynert). 

About  one  million  cells  to  a  square  centimetre  is  the  estimate 
of  Engel. 


Preserving  and  Cutting  the  Brain. 

The  brain  should  be  placed  in  a  gallon  of  a  2^-per-cent  solution 
of  bichromate  of  potassium.  This  must  be  changed  daily  for  a  week, 
then  twice  weekly  for  a  fortnight;  then  it  should  remain  in  the 
solution  for  three  or  four  months,  a  few  crystals  of  thymol  being 
added.  After  about  three  months  place  the  brain  in  95-per-cent 
alcohol.  In  a  few  days  it  will  be  ready  for  cutting.  Or  for  per- 
manent or  temporary  use  the  brain  may  be  placed  in  a  4-per-cent 
solution  of  formalin.  Later  it  may  be  changed  to  alcohol  or 
Bliiller's  fluid. 

In  cutting  the  fresh  or  preserved  brain  for  the  purpose  of  locat- 
ing gross  lesions,  remove  the  pons,  medulla,  and  cerebellum,  place 


Fio.  1  !K5.  — SnowrNo  the  Points  at  which  the  Sections  are  Made.  «,  b,  Horizontal 
line  from  base  of  frontal  to  base  of  occipital  lobe;  A,  vertical  section  through  middle  of 
third  frontal  convolution ;  B,  through  operculum,  o \  C,  through  superior  precentral  and 
lower  end  of  Rolandlc  fissures;  D,  through  re  and  posterior  end  of  Sylvian  fissures;  /•.', 
through  angular  gyrus  and  anterior  occipital  fissure;  /■',  through  parieto-occlpital  fissure. 
/>'  should  be  about  half-way  between  A  and  C  ;  K  half-way  between  1)  and  F.  (See  Figs, 
191-196.) 


382 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


the  brain  on  its  base,  and  make  sections  in  accordance  with  the 
directions  (Fig.  193).  The  sectional  views  exposed  are  shown  in 
the  following  series  of  cuts,  which  are  based  upon  those  of  Exner. 


Fig.  194. — Section  through  Line  -4,  Fig.  193. 


Fig.  lily.— Section  through  Line  B,  Fig.  193. 


ANATOMY    AND    PHYSIOLOGY    OF   THE    BRAIN.  383 


Fig.  196.— Section  through  Line  C,  Fig.  193. 


Fig.  l'JT.— Section  through  Line  /),  Fig.  193. 


384 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


Fig.  1  us. —Section  through  Link  E,  Fig.  193. 


Fig.  10!i.— Section  through  Line  F,  Fig.  193. 


CHAPTER   XVIII. 
DISEASES   OF   THE   BRAIN   AND   ITS   MEMBRANES. 

General  Symptoms. 

It  will  add  to  the  intelligibility  of  descriptions  of  brain  diseases 
and  their  symptoms  if  one  first  makes  himself  familiar  with  certain 
general  symptoms  that  underlie  more  or  less  nearly  all  organic  dis- 
orders of  this  organ.  Symptoms  due  to  disease  of  the  brain  may  be 
placed  in  four  classes :  first,  general  symptoms  of  brain  irritation ; 
second,  general  symptoms  of  brain  presssure ;  third,  symptoms  of 
focal  irritation  or  destruction ;  and,  last,  those  due  directly  to  the 
pathological  process  itself. 

The  symptoms  of  brain  irritation  are  headache,  vertigo,  vomit- 
ing, photophobia,  mental  irritability,  insomnia,  peculiar  feelings  of 
fulness  and  pressure  about  the  head,  noises  in  the  ears  or  in  the 
head,  tenderness  about  the  scalp,  and  in  severe  cases  convulsive 
symptoms  and  delirium. 

The  symptoms  of  brain  compression  are  headache,  vomiting, 
mental  hebetude  or  dulness,  perhaps  some  form  of  paralysis,  con- 
tracted pupils,  and  eventually  coma.  With  this  there  are  often 
constipation  and  retracted  abdomen. 

The  symptoms  of  brain  irritation  are  often,  perhaps  usually,  as- 
sociated with  a  hyperemia.  The  symptoms  of  brain  compression 
may  be  associated  with  anaemia  ov  oedema,  and  often  in  states  of 
malnutrition  in  which  the  brain  is  impoverished  the  symptoms  re- 
semble much  those  of  compression.  Pressure  symptoms  and  irrita- 
tion symptoms  often  lap  one  into  the  other  and  they  cannot  always 
be  sharply  distinguished. 

Focal  symptoms  depend  almost  entirely  upon  the  location  of  the 
particular  lesion.  If  it  is  in  a  motor  area,  focal  symptoms  of  irrita- 
tion would  be  spasmodic  phenomena,  such  as  convulsions.  If  the 
lesion  were  destructive,  the  symptoms  would  be  those  of  paralysis 
or  anaesthesia. 

The  symptoms  due  directly  to  the  pathological  process  itself  may 
be  very  slight.  Thus  in  case  of  a  tumor  of  the  brain  the  symptoms 
are  mainly  caused  by  pressure,  irritation,  and  local  disturbance  of  cer- 
tain special  parts  of  the  brain.  In  suppuration,  however,  the  proc- 
25 


386  DISEASES   OF   THE   NERVOUS    SYSTEM. 

ess  itself  may  produce  genera]  symptoms  such  as  are  associated 
usually  with  sepsis — chills,  irregular  fever,  mental  hebetude,  pros- 
tration, emaciation,  and  sweats. 

Among  the  symptoms  produced  by  focal  lesions  there  are  a  few 
which  deserve  some  preliminary  general  study,  because  they  may  be 
caused  by  lesions  of  very  different  kinds  and  occur  consequently  in 
very  different  forms  of  diseases.  Those  symptoms  which  we  wish 
particularly  to  study  here  are  hemiplegia  and  aphasia.  These 
represent  the  two  great  dominating  symptoms  pertaining  on  the  one 
hand  to  motor  disturbance  and  on  the  other  hand  to  sensori-motor 
disturbance. 

Hemiplegia. — Hemiplegia  is  a  paralysis  of  one  half  of  the  body 
involving  the  side  opposite  the  lesion.  The  face,  arm,  and  leg  are 
usually  all  paralyzed;  the  arm  most,  the  leg  next,  the  face  least. 
Hemiplegia  may  be  either  acute  in  onset  or  slow  and  progressive. 
Acute  hemiplegia  is  the  result  usually  of  hemorrhages  and  soften- 
ings of  the  brain,  more  rarely  of  inflammations  and  injuries.  Pro- 
gressive hemiplegia  begins  gradually,  as  its  name  implies,  and  slowly 
increases  until  the  height  of  the  disease  is  reached.  It  is  usually 
caused  by  tumors  growing  in  one  side  of  the  brain,  but  it  may  be 
caused  by  a  slowly  developing  patch  of  sclerosis,  which  sclerosis  may 
be  in  turn  only  a  part  of  a  multiple  sclerosis.  Further  description 
of  the  peculiarities  of  hemiplegia  will  be  given  under  the  head  of 
Special  Diseases  of  the  Brain. 

Aphasia. — Aphasia  is  a  disorder  of  the  faculty  of  language;  and 
it  has  a  number  of  varieties,  in  accordance  with  the  particular  part 
of  the  brain  involved  and  the  particular  portion  of  the  mechanism 
of  this  faculty  that  is  destroyed.  By  the  faculty  of  language  we 
include  the  processes  by  which  we  hear,  see,  and  at  the  same  time 
appreciate  the  meaning  of  symbols.  It  includes  also  the  faculty  of 
expressing  to  others  by  voice,  writing,  or  gesture  our  ideas.  It  has 
therefore  a  receptive  side  and  an  emissive  side.  We  may  have 
lesions  in  the  brain  which  destroy  that  part  of  the  language  faculty 
concerned  in  our  power  of  seeing  and  understanding  written  words 
or  the  gesture  language.  In  reading  understandingly  one  sees 
certain  words;  these  words  revive  certain  visual  memories  con- 
nected with  past  perceptions.  Thus  one  sees  the  word  "book;" 
this  suggests  to  him  past  memories  of  form,  color,  tactile  and  other 
sensations  associated  with  the  past  perceptions  of  books.  There 
is  a  certain  centre  in  the  brain  where  these  visual  memories 
for  letters  and  words  are  located.  When  this  centre  is  destroyed 
the  memories  are  destroyed  and  the  word  "  book"  or  any  other 
written  word  conveys  no  meaning.     The  patient  can  spell  out  the 


DISEASES   OF   THE   BRAIN   AND    ITS   MEMBRANES.  387 

letters,  he  can  see  the  letters,  but  he  cannot  read  any  more  than 
if  he  had  never  been  taught.  The  condition  is  known  as  alexia  or 
word  blindness.  Again  a  person  may  have  learned  to  associate 
certain  gestures  with  definite  ideas,  as  the  motion  of  carrying  a  glass 
to  the  mouth  with  that  of  drinking,  or  the  motions  of  using  a  knife 
and  fork  with  that  of  eating,  or  the  motions  of  the  deaf-and-dumb 
alphabet  with  certain  words  and  ideas.  These  memories  of  gesture 
language  are  located  in  certain  regions,  and  when  they  are  destroyed 
the  patient  is  no  longer  able  to  understand  gestures  or  the  sign  lan- 
guage. This  condition  is  known  as  sign  blindness.  When  a  person 
is  not  able  to  understand  the  significance  or  uses  of  things  about 
him,  he  has  apraxia.  Apraxia,  sign  blindness,  and  alexia  all  come 
under  the  general  head  of  mind  blindness,  because,  though  the 
patient  can  see,  he  does  not  understand  what  he  sees.  A  person 
hears  certain  words,  as,  for  example,  the  word  "knife."  This  con- 
veys to  him  a  certain  idea  of  the  form,  color,  and  other  properties 
associated  with  knife.  The  memories  associated  with  the  auditory 
perception  of  different  words  are  stored  up  in  a  certain  locality 
which  is  the  centre  for  auditory  memories.  When  this  centre  is 
destroyed  the  person  hears  spoken  words,  but  they  convey  to  him 
no  meaning.  All  that  is  said  to  him  sounds  as  if  it  were  in  a  for- 
eign language :  he  hears,  but  he  does  not  understand.  This  condi- 
tion is  known  as  word  deafness.  So  much  for  the  receptive  or  sen- 
sory side  of  language. 

In  communicating  our  ideas,  we  speak,  write,  and  make  ges- 
tures. In  speaking  we  make  use  of  the  organs  of  articulation,  and 
this  use  involves  the  fine  adjustment  of  a  delicate  muscular  appa- 
ratus. In  the  act  of  expressing  ideas  we  have  to  bring  into  play 
the  memories  of  the  past  muscular  movements  of  this  articulatory 
mechanism.  These  movements  were  learned  by  a  slow  and  painful 
process  during  infancy.  After  the  power  of  speech  is  acquired,  the 
mechanism  works  readily  and  almost  automatically,  because  we  only 
have  to  send  a  stimulus  to  the  centre  which  presides  over  the  stored- 
up  memories  of  the  impulses  to  innervate  properly  the  mechanism 
of  speech.  There  is,  therefore,  a  centre  for  the  memories  of  the 
movements  of  articulation —a  centre  which  is  of  course  closely  con- 
nected with  the  motor  areas  that  directly  innervate  the  larynx, 
pharynx,  and  oral  and  facial  muscles.  When  a  lesion  destroys  this 
centre  for  speech  memories,  a  person  is  unable  to  reproduce  the 
words  necessary  for  expressing  an  idea;  for  example,  he  sees  a 
knife,  he  knows  what  it  is,  but  the  memory  of  the  motions  neces- 
sary to  express  the  word  "  knife"  is  gone.  To  him  it  seems  that 
the  name  is  gone,  and  that  is  the  common  way  of  expressing  it. 


388  DISEASES   OF   THE    XERYOUS    SYSTEM. 

He  cannot  say  the  word  "knife."  The  patient  may  wish  to  express 
the  idea  of  pain.  He  feels  the  pain,  he  knows  that  he  has  pain, 
but  he  cannot  revive  those  motor  memories  which  are  concerned  in 
expressing  the  word  "pain;"  he  cannot  tell,  therefore,  in  words 
what  is  the  matter  with  him.  When  a  person  is  thus  troubled,  he 
is  said  to  have  a  form  of  motor  aphasia  for  which  the  particular 
name  given  is  ap/temia.  In  the  same  way  there  is  a  centre  for  the 
memories  nf  the  muscular  movements  concerned  in  writing;  and 
when  a  lesion  destroys  this  centre  the  patient  is  unable  to  write, 
though  he  may  be  able  to  speak.  This  condition  is  called  agraph  ia. 
There  is  a  centre,  less  well  defined,  for  the  memories  of  the  move- 
ments used  in  gesture  language,  and  when  this  is  destroyed  the 
person  is  unable  to  express  his  ideas  by  gesture  or  sign  language. 
This  condition  is  known  as  amimia.  In  some  cases,  patients  are 
able  to  speak  and  write,  but  they  skip  words,  repeat  often,  and  talk 
confusedly.  There  is  here  a  lesion  of  the  tracts  associating  the  lan- 
guage centres,  and  the  condition  is  called  conduction  aphasia,  while 
to  his  stumbling  speech  the  term  paraphasia  is  given. 

In  attempting  to  classify  these  various  aphasic  conditions  we 
group  together  as  much  as  possible  those  symptoms  which  we  know 
are  related  to  rather  definite  areas  of  the  brain.  The  divisions  are 
based  on  symptoms,  yet  each  symptom  group  has  an  anatomical  seat 
which  in  many  cases  can  be  exactly  determined. 

The  following  are  the  principal  forms  of  aphasia: 

Auditory  aphasia. 

Motor  aphaata,  j  %-£ 

Visual  aphasia. 
Conduction  aphasia. 
Mixed  aphasia. 

Each  of  these  forms  has  certain  subdivisions  of  which  the  analy- 
sis and  recognition  are  matters  of  great  interest,  but  I  shall  only 
suggest  the  lines  along  which  such  investigations  are  pursued.  The 
excessive  use  of  diagrams  has  filled  up  literature  with  exceptional 
cases  and  impaired  the  clearness  and  sense  of  proportion  with 
which  the  clinical  pictures  of  aphasia  should  be  presented.  No 
doubt,  however,  the  ultimate  result  will  be  useful. 

In  the  examination  of  a  case  of  aphasia,  the  following  twelve 
questions  should  always  be  put  to  the  patient : 

1.  Can  he  hear  sounds? 

2.  Can  he  hear  spoken  words'.' 

3.  Can  he  understand  the  words  spoken? 

4.  Can  he  see  objects? 


DISEASES   OF   THE   BRAIN"   AND    ITS   MEMBRANES.  389 

5.  Can  he  see  words  written  or  printed,  and  read  them  silently? 

6.  Can  he  understand  written  or  printed  words,  i.e.,  can  he  read 
intelligently? 

7.  Can  he  speak  voluntarily? 

8.  Can  he  repeat  words? 

9.  Can  he  read  aloud? 

10.  Can  he  write  voluntarily? 

11.  Can  he  write  to  dictation? 

12.  Can  he  copy? 

In  auditory  aphasia,  the  principal  symptom  is  that  the  patient 
has  word  deafness.  He  is  unable  to  understand  spoken  language, 
though  he  hears  the  sounds  and  is  not  at  all  deaf.  The  lesion  is  in 
the  first  and  second  temporal  convolutions  of  the  left  hemisphere. 
When  the  lesion  is  extensive,  the  patient  has  many  other  aphasic 
symptoms,  because  all  speech  centres  are  closely  united  functionally. 
Visual,  auditory,  and  articulatory  memories  are  brought  into  play 
together,  and  form  a  kind  of  internal  language  circuit  around  "which 
the  nerve  impulses  play  in  the  production  of  speech.  If  now  a  pa- 
tient has  an  auditory  aphasia  with  deep  and  extensive  injury  of  the 
temporal  lobe,  it  will  be  found  that  he  cannot  understand  spoken 
words,  neither  can  he  read  intelligently.  He  cannot  repeat  words 
or  read  aloud,  and  he  cannot  write  to  dictation,  nor  copy.  He  can 
speak  voluntarily,  however,  but  he  skips  words  and  is  paraphasia 
This  form  is  called  cortical  sensory  aphasia  (Wernicke).  If  the 
lesion  is  smaller,  or  if  the  case  improves  and  the  injured  tissue  to 
some  extent  heals,  it  will  be  found  that  the  patient  still  has  word 
deafness  and  cannot  repeat  words  or  write  to  dictation ;  but  he  can 
talk  and  read  and  write  voluntarily.  This  forms  a  subcortical 
aphasia. 

In  motor  aphasia  or  aphemia  the  principal  symptom  is  that  the 
patient  cannot  speak  voluntarily,  he  cannot  repeat  words  or  read 
aloud.  He  cannot  write  voluntarily  or  to  dictation,  but  he  can  copy. 
He  hears,  sees,  understands  both  written  and  spoken  language. 
This  is  the  most  common  type  of  aphasia  and  its  seat  is  known  to 
be  in  Broca's  convolution,  i.e.,  the  third  left  frontal.  In  its  com- 
pleter type  as  given  above  it  is  called  cortical  motor  aphasia,  but 
this  means  nothing.  In  severe  cases,  the  patient  cannot  read  un- 
derstandingly  except  to  a  limited  extent  and  the  power  of  under- 
standing spoken  words  is  also  impaired.  On  the  other  hand,  in 
lighter  forms  the  patient  can  read  and  write  and  understand,  and 
has  lest  only  the  power  of  voluntary  speech,  of  repeating  words  and 
reading  out  loud. 

Agraphia  is  a  symptom  of  nearly  all  the  forms  of  aphasia.      It 


39U  DISEASES   OF   THE    NERVOUS   SYSTEM. 

is  oftenest  seen  in  aphemia  and  is  most  complete  in  this  type. 
There  is  no  form  of  aphasia,  however,  in  which  agraphia  is  the  only, 
symptom,  and  the  evidence  of  a  writing  or  graphic  centre  in  the 
cortex  is  not  proven,  though  it  is  probable. 

Visual  aphasia  is  accompanied  by  an  inability  to  read  words 
understandingly,  though  the  patient  can  see  them.  He  is  able  to 
speak  and  understand  spoken  words.  Alexia  is  thus  the  character- 
istic symptom.  There  are  often  hemianopsia  and  some  hemiataxia 
or  anaesthesia.  Two  principal  forms  have  been  described.  In  one 
there  is  considerable  agraphia,  as  well  as  inability  to  read  either 
silently  or  aloud.  Here  the  lesion  involves  the  cortex  of  the  angu- 
lar gyrus  and  supramarginal  lobule  (cortical  alexia).  In  the  other 
form,  the  patient  -has  a  pure  alexia,  and  can  write  though  he  cannot 
copy.  There  is  usually  hemianopsia  present.  The  lesion  here  is  in 
the  subcortical  substance  of  the  angular  gyrus. 

Conduction  and  Mixed  Aphasia. — There  are  very  few  cases  of 
pure  conduction  aphasia.  When  it  occurs  there  is  paraphasia  and 
paragraphia ;  the  patient  repeats  words  over  and  over  in  a  kind  of 
verbal  intoxication,  or  mixes  things  so  that  the  speech  is  almost  gib- 
berish. Still  he  can  express  himself  and  can  write,  read,  and 
understand.  The  lesion  is  usually  in  the  island  of  Eeil  or  the  con- 
volutions about  the  fissure  of  Sylvius. 

Practically  conduction  aphasia  is  usually  mixed  with  a  visual 
or  auditory  aphasia. 

Malformations  of  the  Brain  and  its   Envelopes. 

Congenital  malformations  of  the  brain  are  of  little  practical  im- 
portance, for  in  most  cases  the  monsters  cannot  live  and  in  all 
cases  they  are  better  dead.  I  shall  simply  give  a  brief  enumeration 
of  the  important  forms. 

{Anencephaly. 
Micrencephaly  and  microcephaly. 
Porencephaly. 
Absences  or  malformations  of  parts,  e.g.,  cyclopia. 

Abnormal  i  t  i  e  s  f  tC™?Jh. 


■T,      uuc,    I  Meningocele, 
of   brain    and  ■{  -^         P  ,      , 
its  envelones     I   Encephalocele. 
its  envelopes.    ^  Hydrencephalo 


Hydrencephalocele. 

Anencephaly  is  always  present  with  acrania.  In  anencephaly 
the  cerebellum  and  part  of  the  basal  ganglia  may  be  present.  In 
such  case  the  child  can  live  a  short  time  (Fig.  200). 

Micrencephaly  and  Microcephaly. — Micrencephaly  is  a  condition 
in  which  the  brain  is  only  partially  developed.  If,  as  is  usually  the 
case,  the  cranium  is  also  abnormally  small,  it  is  called  microcephaly. 
It  is  due,  probably,  in  all  cases  to  an  inherent  defect  in  the  growth 


DISEASES   OF   THE    BRAIN    AXD    ITS    MEMBRAXES. 


391 


of  the  brain.     Virchow  has  asserted,  however,  that  there  is  a  form 
in  which  the  abnormality  is  caused  by  a  premature  growing  together 


Fig.  200.— Acraxia. 


of  the  cranial  bones,  a  micrencephaly  being  a  result  of  the  mechani- 
cal condition.     An  adult  cranium  whose  gross  circumference  meas* 


Fn;.  201—  Cyclopia. 


ures  less  than  43  cm.  will  contain  a  micrencephalic  brain.     The 
normal  minimum  weight  of  the  adult  brain  is  (.m;o  grama  for  man 


392  DISEASES   OF   THE    NERVOUS    SYSTEM. 

and  880  for  woman.  It  should  bear  the  ratio  to  the  body  at  birth 
of  14  per  cent,  and  of  2.37  per  cent  in  adult  life  (Vierordt). 

Porencephaly  is  often  an  artificial  condition.  It  will  be  de- 
scribed later. 

In  cyclopia  there  is  an  undivided  anterior  cerebral  vesicle ;  the 
orbits  form  a  continuous  cavity  with  a  single  rudimentary  eye  (Fig. 
201). 

Meningocele  is  a  hernia  of  the  brain  membranes,  arachnoid,  and 
dura  mater  through  a  cleft  in  the  skull.  In  encephalocele  the  brain 
also  protrudes.  Both  these  forms  occur  usually  in  the  occipital  region 
and  almost  invariably  in  the  median  line.  In  hydr encephalocele 
there  is  a  sac  with  fluid  contents. 


Diseases  of  the    Membranes  of  the  Brain. 

The  diseases  to  be  considered  under  this  head  are  anaemia  and 
hyperaeniia,  inflammation  of  the  dura  mater  or  pachymeningitis,  and 
inflammation  of  the  pia  mater  or  leptomeningitis. 

Anaemia  and  Hyperemia  of  the  Membranes  of  the 
Brain.  — Anaemia  of  the  membranes  of  the  brain  is  a  condition  that 
cannot  be  separated  from  anaemia  of  the  brain  substance,  and  will 
be  considered  in  connection  with  it.  Hyperaeniia  of  the  brain 
membrane,  so  far  as  it  relates  to  hyperaeniia  of  the  pia  mater,  must 
also  be  considered  in  connection  with  hyperaeniia  of  the  brain  tissue. 
Dural  hyperaeniia,  or  congestion  of  the  dura  mater,  is  a  condition 
which  occurs  as  the  result  of  injuries,  sunstroke,  and  of  certain  in- 
fective poisons,  especially  that  of  syphilis.  The  symptoms  are 
those  of  pachymeningitis  of  the  slight  grade,  and  will  be  described 
under  that  head.  They  consist  mainly  of  pain,  occasional  attacks 
of  vertigo,  and  sensations  of  fulness  about  the  head.  The  treatment 
is  that  for  the  beginning  stages  of  a  meningitis. 

Inflammation  of  the  Duka  Mater  or  Pachymeningitis 
Externa. — It  has  been  the  custom  to  describe  two  forms  of  pachy- 
meningitis, the  external  and  the  internal.  Internal  pachymenin- 
gitis, or  haematoma  of  the  dura  mater,  is  properly  a  hemorrhagic 
disorder,  and  is  described  under  the  head  of  Dural  Hemorrhages.  A 
true  inflammation  confined  to  the  internal  surface  of  the  dura  alone 
is  of  extremely  rare  occurrence. 

Pachymeningitis  externa  is  a  disease  that  involves,  at  first  at 
least,  the  outer  surface  of  the  dura,  and  is  usually  of  surgical  origin 
and  interest. 

Etiology. — Accidents,  injuries,  caries  of  the  petrous  bone  in 
mastoid  disease,  of  the  ethmoid  bone  in  ozaena,  necrosis,  syphilis, 
and  erysipelas  are  the  usual  causes. 


DISEASES   OF   THE   BRAIN    AXD    ITS   MEMBRANES.  393 

The  symptoms  are  local  headache,  fever,  delirium,  sometimes 
even  convulsions  and  paralysis.  In  the  severe  cases  the  disease  has 
usually  extended  and  involved  the  pia.  Pus  is  generally  formed, 
and  burrows  between  the  bone  and  dura.  The  disease  is  recognized 
mainly  by  the  discovery  of  the  local  cause. 

The  course  is  acute  or  subacute. 

The  treatment  is  a  surgical  one. 

Inflammation  of  the  Pia  Mater,  or  Leptomexixgitis. — In- 
flammation of  the  pia  mater  has  the  following  types :  simple  menin- 
gitis due  to  some  infection,  epidemic  cerebro-spinal  meningitis  due 
to  a  specific  general  infection,  tuberculous  meningitis,  serous  menin- 
gitis, and  syphilitic  meningitis. 

Jlost  of  all  these  forms  of  meningitis  may  be  either  acute  or 
chronic,  the  chronic  form  being  usually  simply  a  sequela  of  the 
acute. 

Acute  Simple  Leptomeningitis — Etiology. — Acute  lepto- 
meningitis is  always  due  to  an  infective  process  reaching  the  cere- 
bral membranes  usually  directly  from  without,  but  sometimes 
through  the  blood.  Trauma,  and  especially  acute  alcoholism  pre- 
dispose to  this.  The  most  common  source  of  infection  is  disease 
of  the  middle  ear  and  mastoid  cells.  Disease  of  the  frontal  sinuses 
and  upper  nasal  passages;  operations  on  those  parts;  disease,  in- 
juries, and  fractures  of  the  cranial  bones — are  also  common  causes. 
Pneumonia  is  the  most  frequent  infective  disease  in  which  the  pyo- 
genic organisms  are  carried  by  the  blood.  After  this  come  pyaemia, 
septicaemia,  variola,  scarlet  fever,  more  rarely  endocarditis,  empy- 
ema, rheumatism,  measles,  typhoid  fever,  and  mumps.  Occasion- 
ally a  brain  abscess  reaches  the  surface  and  sets  up  a  meningitis. 
Insolation  can  of  itself  not  cause  it.  The  disease  is  more  frequent 
in  males,  and  is  distributed  through  all  ages  of  life,  though  it  oc- 
curs oftener  in  the  young. 

Symptoms. — The  symptoms  in  the  various  types  differ  somewhat, 
but  have  a  general  similarity.  They  are  to  be  broadly  grouped  into 
the  prodromal,  the  irritative,  the  depressive,  and  the  paralytic 
stages. 

Prodromal  symptoms  are  shorter  and  less  marked  in  simple  men- 
ingitis than  in  tubercular.  The  patient  suffers  from  malaise, 
languor,  headache,  vertigo,  irritability,  loss  of  appetite,  and  vomit- 
ing.    Of  these  symptoms  headache  is  the  most  notable. 

In  the  second  stage  the  dominant  symptoms  are  headache,  de- 
lirium, rigidity  of  the  neck,  hyperesthesia  of  the  skin,  retraction 
of  the  abdomen,  vomiting,  irregular  fever,  contracted  and  often  on- 
equal  pupils,  sometimes  optic  neuritis  or  retinitis.     The  headache 


394  DISEASES   OF    THE    NERVOUS   SYSTEM. 

is  usually  persistent,  with  exacerbations  of  great  intensity.  Rather 
early  in  this  disease  the  patient's  mind  begins  to  wander;  he  mutters 
incoherently;  he  may  have  periods  of  violence  alternating  with 
stupor.  In  some  cases  there  is  a  continuous  low  muttering  delirium. 
Vomiting  also  occurs  early  and  is  of  a  violent,  explosive  (projectile) 
character.  This  symptom  is  not  always  present.  The  head  is  bent 
back  and  the  patient  can  be  lifted  from  the  pillow  by  placing  the 
hand  under  the  occiput.  There  is  sometimes  a  general  rigidity 
which  resembles  catalepsy.  Drawing  a  dull  point  along  the  skin 
causes  a  red  line  to  appear  (tacit e  cerebrate).  Pinching  or  rubbing 
the  skin  causes  much  pain.  The  abdomen  falls  in  and  assumes  a 
characteristic  "  boat  shape."  The  pupils  are  usually  contracted  and 
uneven.  The  eyes  are  intolerant  of  light.  Optic  neuritis  occurs 
often  when  the  inflammation  is  at  the  base,  but  it  is  a  late  symp- 
tom. Convulsions  and  local  paralyses  of  the  cranial  nerves,  causing 
slight  strabismus,  ptosis,  or  facial  palsy,  may  occur.  The  fever  is 
irregular  in  course  and  not  high — 101°  to  103°.  The  pulse  is 
usually  irregular  or  rather  intermittent.  It  varies  greatly  in  fre- 
quency and  may  be  rather  slow — 50  to  70.  Respiration  is  rather 
quickened  and  sometimes  irregular.  The  bowels  are  constipated; 
the  urine  is  small  in  amount  and  sometimes  albuminous. 

In  the  paralytic  stage  the  patient  becomes  stupid  or  comatose ; 
there  is  still  some  rigidity,  except  in  the  very  last  stages.  The 
abdomen  is  still  greatly  retracted,  the  pupils  may  now  dilate,  the 
skin  become  moist,  and  the  patient's  bowels  and  bladder  move 
involuntarily.     Death  then  occurs  in  one  or  two  days  as  a  .ule. 

When  the  disease  is  mainly  on  the  convexity  of  the  hemispheres 
there  are  more  delirium,  convulsive  and  paralytic  troubles;  when 
confined  to  the  base  there  is  less  delirium,  while  paralysis  of  cranial 
nerves,  optic  neuritis,  vomiting,  and  retraction  of  the  head  are  com- 
moner or  more  prominent. 

Course  and  Duration. — The  disease  may  begin  suddenly,  and  the 
patient  pass  at  once  into  the  comatose  state,  dying  in  a  few  days. 
Usually  the  process  lasts  one  or  two  weeks;  it  may  be  prolonged 
for  several  weeks. 

The  prognosis  is  very  grave,  but  it  is  less  serious  than  in  tuber- 
culous meningitis  and  more  serious  than  in  the  cerebro-spinal  form. 

The  diagnosis  is  based  on  the  presence  of  an  exciting  cause,  such 
as  disease  of  the  ear  or  nose,  trauma,  infective  fevers,  and  upon 
the  presence  of  the  symptoms  given.  It  is  usually  easily  recog- 
nized, the  main  difficulty  being  to  distinguish  it  from  tuberculous 
and  cerebro-spinal  meningitis. 

To  assist  in  diagnosis  it  is  permissible  to  make  a  lumbar  punc- 
ture, draw  off  the  fluid,  and  examine  it  for  bacteria. 


DISEASES   OF   THE    BRAIN    AND    ITS   MEMBRANES.  395 

Pathology. — The  disease  is  a  fibro-purulent  or  purulent  inflam- 
mation. It  involves  usually  the  base  more  than  the  convexity,  but 
the  reverse  may  happen.  The  ventricles  are  often  involved  and 
may  be  independently  inflamed.  There  are  descriptions,  therefore, 
of  simple  basilar  meningitis,  meningitis  of  the  convexity,  and  ven- 
tricular meningitis  or  ependymitis.  The  inflammatory  deposits  are 
most  conspicuous  along  the  course  of  the  Sylvian  fissure  and  the 
vessels  branching  from  it,  about  the  optic  chiasm,  and  at  the  pos- 
terior and  under  surface  of  the  cerebellum  and  the  sides  of  the  pons. 
It  may  lie  only  in  the  subarachnoid  cavity,  but  usually  the  ara<  h- 
noid  and  sometimes  the  dura  are  implicated.  There  is  increase  of 
fluid  in  the  ventricles  and  arachnoid  cavities,  and  this  fluid  may  be 
turbid.  The  surface  of  the  ventricles  may  show  an  inflammatory 
process. 

The  micro-organisms  found  in  meningitis  are  the  pneumococcus, 
streptococcus  pyogenes,  intracellular  diplococcus,  the  pneumo-bacil- 
lus,  and  a  bacillus  resembling  that  of  typhoid  fever.  Still  others 
have  been  described,  and  the  process  is  apparently  a  mixed  infec- 
tion, though  the  pneumococcus  is  found  oftenest. 

Treatment. — Prophylaxis  is  the  most  important  measure,  as  there 
is  no  specific  treatment.  Chronic  disease  of  the  ear  and  nasal 
sinuses  should  be  attended  to,  and  injuries  of  the  skull  treated  with 
the  strictest  regard  to  antisepsis.  The  patient  should  be  kept  quiet, 
a  dose  of  calomel  given,  and  small  doses  of  iodide  of  potassium  ad- 
ministered at  frequent  intervals.  An  ice  cap  may  be  applied  to 
the  head  and  hot  applications  to  the  feet.  Hot  poultices  along  the 
upper  spine  are  useful.  Opium  must  be  given  for  the  pain,  if 
needed;  and  antipyretics  or  phenacetin  sometimes  answer,  in  a 
measure.  The  internal  use  of  iodoform  has  been  highly  recom- 
mended, gr.  vi.  to  gr.  xij.  daily;  shaving  the  head  and  rubbing 
upon  it  an  ointment  containing  twenty  per  cent  iodoform,  then  cov- 
ering the  scalp  with  an  oiled-silk  cap,  is  a  treatment  highly  spoken 
of.     Surgical  intervention  is  sometimes  justifiable. 

Epidemic  Cerebro-Spixal  Meningitis  (Spotted  Fever). — 
This  is  an  acute  infective  disorder  and  is  produced  by  a  special 
micro-organism.  It  has  certain  peculiar  clinical  characteristics 
which  lead  us  to  describe  it  separately.  Anatomically  the  changes 
involve  the  spinal  membranes  as  well  as  the  cerebral. 

Etiology. — The  disease  most  frequently  attacks  children,  but  it 
may  occur  at  any  age.  Males  are  affected  rather  more  often  than 
females.  It  prevails  in  the  form  of  epidemics  which  affect  cold  and 
temperate  climates  especially,  and  which  travel  from  one  part  of  the 
country  to  another.  It  may  occur  sporadically.  It  most  frequently 
develops  during  the  winter  season,  and  attacks  persons  who  are 


396  DISEASES   OF   THE    NEEVOUS   SYSTEM. 

living  in  crowded  houses,  tenements,  or  barracks.  It  is  slightly 
contagious.  One  attack  does  not  confer  an  immunity  against  a 
second. 

Symptoms, — The  general  appearance  of  a  person  attacked  with 
the  disease  is  that  of  one  Avho  has  been  poisoned  by  some  agent 
which  is  extremely  prostrating  to  the  whole  system  and  at  the  same 
time  one  which  has  a  specific  inflammatory  effect  upon  the  meninges 
of  the  brain  and  spinal  cord.  When  the  disease  is  rapid  and  ma- 
lignant, the  patient  seems  to  die  of  an  aeute  toxaemia  before  any 
inflammatory  process  has  time  to  develop.  In  milder  cases  and 
those  of  longer  duration  the  prostration  is  less,  and  the  evidences 
of  inflammation  of  the  meninges  then  develop  in  the  typical  way. 

The  disease  may  begin  with  prodromal  symptoms  of  malaise,  dis- 
comfort, pain  in  the  neck,  vomiting,  and  headache.  As  it  develops, 
the  headache,  accompanied  by  giddiness,  increases,  pain  and  stiff- 
ness in  the  neck  become  more  marked,  pains  run  down  the  back  and 
radiate  to  the  limbs ;  there  is  photophobia,  and  delirium  in  many 
cases  is  present.  The  skin  is  hypersesthetic ;  the  pulse  rises  to  120 
or  higher;  the  temperature  varies  very  much  and  is  usually  raised 
to  103°,  104°,  or  even  more.  The  bowels  are  generally  constipated. 
In  most  cases  there  develop  certain  skin  eruptions,  usually  in  the 
form  of  purpuric  spots;  herpes,  urticaria,  and  erythema  are  occa- 
sionally seen.  These  eruptions  vary  very  much  in  different  epi- 
demics; the  purpuric  spots  are  the  most  important  from  a  diagnostic 
point  of  view,  and  have  given  to  the  disease  the  name  of  spotted 
freer.  As  the  disease  progresses  the  symptoms  of  irritation  and 
pain  give  Avay  to  those  of  somnolence,  stupor,  and  paralysis.  Optic 
neuritis,  acoustic  neuritis,  and  inflammation  of  other  cranial  nerves 
take  place,  and  paralyses  of  the  limbs  may  be  added. 

The  disease  may  run  a  short  and  malignant  course,  killing  the 
person  in  a  few  hours  or  one  or  two  days.  In  moderate  cases  it 
lasts  about  two  weeks.  A  large  number  of  different  varieties  of  the 
disease  are  described,  such  as  the  abortive  form,  fulminating  form, 
and  typhoid  form.  The  disorder  is  often  complicated  with  pneu- 
monia and  bronchitis,  less  often  with  inflammation  of  the  joints  and 
serous  membranes.  The  disease  often  leaves  very  serious  sequelae, 
the  most  important  being  deafness  and  spinal  irritation  or  chronic 
spinal  meningitis.  A  large  number  of  deaf  mutes  owe  their  afflic- 
tion to  this  disease. 

Pa&koloffioal  Anatomy. — In  the  very  acute  cases  the  post-mortem 
shows  nothing  but  the  evidence  of  very  severe  blood-poisoning.  In 
the  milder  and  more  chronic  cases  an  inflammation  involving  the 
pia  and  arachnoid  of  the  brain  and  cord  is  found.     This  inflamma- 


DISEASES   OF   THE   BRAIN   AND    ITS   MEMBRANES.  397 

tion  is  fibrinous  or  fibro-purulent  in  character,  and  may  be  accom- 
panied with  the  exudation  of  a  good  deal  of  inflammatory  material. 
Bacteriological  researches  show  that  this  disease  is  due  to  the  pres- 
ence of  a  specific  micro-organism  which  is  apparently  very  much 
like  that  which  causes  pneumonia. 

The  diagnosis  is  based  upon  the  history  of  an  epidemic  of  the 
disease  being  present,  upon  the  presence  of  the  ordinary  symptoms 
of  acute  cerebral  and  spinal  meningitis,  such  as  headache,  delirium, 
retraction  of  the  head,  the  sunken  abdomen,  hyperesthesia,  and 
pains;  finally,  the  presence  of  the  peculiar  purpuric  spots  or  of 
herpes  of  the  face  will  enable  one  to  make  a  positive  diagnosis. 
One  must  learn  to  distinguish  the  disease  from  typhus,  tetanus, 
imemia,  pneumonia,  and  from  the  other  forms  of  meningitis,  espe- 
cially the  tuberculous.  The  diagnosis  is  often  made  difficult  by  the 
fact  that  cerebro-spinal  meningitis  may  occur  in  a  sporadic  form, 
and  it  is  well  known  that  after  a  community  has  been  once  visited 
by  an  epidemic  these  sporadic  cases  are  apt  to  crop  up  from  time 
to  time  for  many  subsequent  years.  The  sudden  onset  of  the  dis- 
ease, the  spinal  symptoms,  the  skin  eruption,  the  absence  of  his- 
tory of  injury  or  of  evidence  of  tuberculosis  will  usually  enable  one 
to  recognize  the  disorder.      Lumbar  puncture  may  be  used. 

The  pro'jnosis  varies  much  with  the  epidemic,  but  the  disease  is 
always  a  serious  one.  The  mortality  ranges  from  twenty  to  eighty 
per  cent;  it  is  worse  when  the  disease  comes  on  suddenly  and 
severely,  with  early  coma.  It  is  better  in  persons  over  the  age  of 
ten.  Cranial -nerve  complications  are  unfavorable,  in  that  they 
are  apt  to  leave  permanent  deafness.  Severe  spinal  complications 
are  apt  to  leave  their  mark  in  the  form  of  a  chronic  meningeal 
trouble. 

Treatment — There  is  no  specific  remedy  for  the  disease,  and  the 
ordinary  antiphlogistic  measures  such  as  mercury  and  iodides  are  of 
.  alue  than  in  other  forms  of  meningitis.  The  patient  should 
l>e  given  sustaining  food,  and  everything  possible  should  be  done  to 
counteract  the  depressing  effects  of  the  toxaemia.  Opium  or  mor- 
phine internally,  chloral,  digitalis,  quinine,  benzoate  of  sodium  and 
salicylate  of  sodium,  and  alcohol  are  the  drugs  which  have  been  spe- 
cially recommended.  Warm  baths,  hot  moist  applications,  and 
leeches  have  all  been  tried  with  more  or  less  good  results. 

TrBKRCULOus  Menlntgitis  (Acute  Hvm:o<  epuai  is).  — This  is 
a  form  of  meningitis  due  to  infection  with  the  bacillus  tuberculosis. 
It  differs  pathologically  from  other  forms  in  the  character  of  the 
infective  organism;  anatomically,  in  the  fact  that  the  inflammation 
is  usually  and  chiefly  basilar  and  never  purely  purulent;  etiologi- 


398  DISEASES   OF   THE   NERVOUS   SYSTEM. 

cally,  in  that  it  chiefly  affects  young  children;  and  symptomatologi- 
cally,  in  the  presence  of  prodroinata  and  a  more  irregular  course. 

Etiology. — Tuberculous  meningitis  occurs  chiefly  between  the 
ages  of  two  and  ten,  sometimes  in  infancy,  rarely  in  adult  life,  very 
rarely  after  the  age  of  fifty.  Males  are  rather  more  subject  to  it. 
A  hereditary  history  of  phthisis,  a  scrofulous  diathesis,  bad  hygienic 
surroundings,  and  the  presence  of  tuberculosis  elsewhere  in  the  body 
predispose  to  it.  Tuberculous  milk,  the  eruptive  fevers,  especially 
measles,  blows  on  the  head,  and  great  emotional  excitement  appear 
to  act  as  exciting  causes. 

Symptoms. — A  knowledge  of  the  prodromal  symptoms  is  espe- 
cially important.  These  are  paroxysmal  and  intensely  severe  head- 
aches and  darting  pains  in  the  head,  vertigo,  loss  of  appetite,  ex- 
plosive vomiting  without  nausea,  the  vomited  matter  being  usually 
colorless  and  watery,  constipation,  an  altered  disposition,  and  irri- 
tability. The  tache  cerebrate  or  cerebral  macule,  more  rarely  ptosis 
and  facial  paralysis  may  appear  early.  The  prodromal  stage  often 
lasts,  with  remissions,  three  or  four  weeks.  When  the  disease  sets 
in  there  is  more  persistent  headache ;  vomiting,  fever,  and  the  other 
symptoms  of  meningitis  already  described  appear.  The  irritative 
stage  gradually  passes  into  the  paralytic  and  comatose.  Death 
occurs  in  two  or  three  weeks.  In  infants  the  disease  often  runs  a 
very  obscure  course,  the  patient  showing  chiefly  symptoms  of  brain 
compression. 

Pathological  Anatomy. — In  rapidly  fatal  cases,  with  severe  symp- 
toms, there  may  be  only  an  intense  congestion  of  the  brain  with 
numerous  miliary  tubercles  in  the  pia  mater  at  the  base  and  over 
the  convexity.  Here  we  must  assume  that  a  bacillary  toxin 
causes  the  symptoms.  In  most  cases  there  are  decided  deposits  of 
tubercles  at  the  base,  with  fibrinous  inflammatory  deposits  about 
the  optic  chiasm,  along  the  fissure  of  Sylvius,  at  the  sides  of  the 
pons,  and  elsewhere.  Miliary  tubercles  are  seen  scattered  over  the 
convexity  and  in  the  choroid  plexus  and  ventricles.  They  are  gen- 
erally found  in  the  spinal  membranes  also,  especially  over  the  cauda 
equina.  The  tubercles  lie  beneath  the  pia  surrounding  the  small 
vessels.  They  may  coalesce  into  large  tuberculous  nodules.  There 
is  usually  an  increase  in  the  arachnoid  fluid,  and  in  most  cases  an 
increase  in  the  ventricular  fluid.  Somewhat  rarely  there  are  very 
great  distention  of  the  ventricles  and  compression  of  the  convolu- 
tions. This  condition  used  to  be  called  acute  hydrocephalus.  Small 
spots  of  softening  may  be  seen  from  obliteration  of  the  vessels  by 
the  tubercles.  The  bacillus  tuberculosis  is  found  in  the  tuberculous 
nodules. 


DISEASES   OF   THE    BRAIN    AND    ITS   MEMBRANES.  399 

Diagnosis. — As  regards  the  form  of  the  disease,  this  is  based  on 
the  hereditary  history,  the  age,  the  existence  of  tuberculosis  of  the 
lungs  or  other  organs,  and  the  peculiar  prodromata  of  the  disease. 
Occasionally  tubercles  can  be  seen  on  the  choroid.  Lumbar  punc- 
ture of  the  spinal  canal  with  withdrawal  of  fluid  and  its  examina- 
tion for  bacillus  is  a  method  of  diagnosis  which  may  be  tried. 

Prognosis. — This  is  usually  absolutely  bad,  yet  post-mortem  ob- 
servation of  patients  dying  with  practically  no  inflammatory  change 
makes  it  seem  possible  that  the  disease  might  be  checked,  aud  a 
good  many  cases  are  reported  in  which  it  apparently  has  been  done. 
Some  of  these  are,  however,  probably  cases  of  hereditary  syphilis. 

Treatment. — So  far  as  is  now  known,  this  is  not  different  from  that 
given  under  the  head  of  meningitis  elsewhere.  It  seems,  however, 
as  if  in  time  some  antitoxin  may  be  discovered  which  will  check 
the  progress  of  the  poison  and  the  development  of  the  tubercle ; 
meanwhile  the  best  thing  to  do  is  to  give  small  doses  of  iodide  of 
potassium  at  frequent  intervals  and  use  symptomatic  treatment. 

Chronic  Hydrocephalus. 

This  is  a  disease  mainly  of  infancy,  characterized  by  a  gradual 
enlargement  of  the  head,  with  mental  deficiency  and  symptoms  of 
brain  irritation  caused  by  an  accumulation  of  fluid  in  the  ventricles 
of  the  brain. 

The  old  term,  "acute  hydrocephalus,"  meant  an  acute  inflamma- 
tion with  effusion,  but  the  name  is  not  needed  and  is  best  dropped. 
Chronic  hydrocephalus  is  not  an  inflammatory  process,  but  one  due 
to  mechanical  causes  or  to  defects  in  structure  or  nutrition.  The 
fluid  always  accumulates  in  the  ventricles  of  the  brain;  hence 
chronic  hydrocephalus  is  always  internal.  The  so-called  external 
forms  of  hydrocephalus  are  inflammatory  or  else  are  secondary  to 
meningeal  hemorrhage  or  brain  atrophy.  Chronic  hydrocephalus 
is  almost  always  a  disease  of  infancy  and  is  generally  congenital. 
It  may,  however,  be  acquired.  In  speaking  of  chronic  hydrocepha- 
lus, we  refer  to  the  chronic  internal  congenital  disease. 

Etiology. — Four  out  of  five  cases  begin  at  birth  or  within  the  first 
six  months  of  life.  Syphilis  (J.  Lewis  Smith),  alcoholism,  lead 
poisoning  in  the  parents,  and  some  unknown  family  taint  predispose 
to  the  disease.  Poverty  and  poor  nutrition  and  rickets  are  also 
factors. 

Symptoms. — The  head  may  be  so  large  at  birth  that  instrumental 
help  is  needed.  More  often  the  parents  notice  a  gradual  increase 
in  the  size  of  the  child's  head,  beginning  soon  after  birth.     The 


400 


DISEASES    OF   THE   NERVOUS    SYSTEM. 


forehead  bulges,  the  occiput  stands  out,  the  fontanelles  and  sutures 
widen,  and  pressure  shows  evidence  of  fluctuation.  Meanwhile  the 
face  does  not  grow  much  and  the  result  is  to  give  a  triangular  shape 
to  the  head.  It  may  measure  twenty-four,  twenty-seven  and  one- 
half  (Minot),  thirty-two  (Bright),  and  even  forty-three  inches 
(Klein)  in  diameter.  These  extreme  measurements  are  reached 
only  after  one  or  two  years.  With  this  abnormal  growth  of  the 
head,  mental  and  physical  symptoms  appear.  The  infant  is  restless 
and  irritable;  its  appetite  may  be  good,  but  the  general  nutrition  is 
poor  and  its  bodily  growth  is  retarded.  The  mind  does  not  de- 
velop; usually  it  does  not  or  cannot  learn  to  walk.  It  may  be  un- 
able to  support  the  weight  of  its  head.     There  is  strabismus  and 


Fig.  202. — Chronic  Hydrocephalus. 

sometimes  optic  atrophy.  The  pressure  of  the  dropsy  thins  the 
orbital  bones  and  forces  down  the  axis  of  the  eyeballs  (see  Fig. 
202).  Vomiting,  coma,  and  convulsions  eventually  appear,  and 
the  child  dies  of  exhaustion  or  some  intercurrent  disease  in  two  or 
three  years. 

In  some  cases  the  trouble  is  less  serious,  it  ceases  to  progress, 
the  bones  solidify,  and  the  child  grows  up  with  good  intelligence. 

Chronic  hydrocephalus  sometimes  develops  in  late  childhood  and 
in  adult  life.  It  is  then  due  to  some  tumor  or  inflammatory  process 
obstructing  the  vena?  Galeni  and  the  aqueduct  of  Sylvius.  The 
symptoms  are  chiefly  those  of  brain  pressure,  and  the  disease  cannot 
be  recognized  with  certainty. 

The  hydrocephalus  which  is  associated  with  the  brain  atrophy 
of  insanity  and  old  age  or  with  general  dropsical  conditions  has  no 
kinship  with  the  process  we  are  now  describing. 

Pathology. — The  disease  is  due  to  the  gradual  accumulation  of 


DISEASES   OF   THE    BRAIN    AND    ITS   MEMBRANES.  401 

a  serous  fluid  in  the  ventricles  of  the  brain.  The  cause  of  this  is 
an  inflammatory  or  developmental  obliteration  of  the  aqueduct  of 
Sylvius  or  the  foramen  of  Magendie  and  the  adjacent  lateral  fora- 
mina of  Mierziejewski.  This  prevents  the  escape  of  the  ventricular 
fluid  into  the  general  arachnoid  cavity.  Contributing  factors  are 
congenital  or  acquired  defect  in  the  absorbents  of  the  ventricles  and 
a  rachitic  and  easily  yielding  skull.  The  attempts  to  make  chronic 
hydrocephalus  an  inflammation  are  failures,  though  there  is  at  times 
a  thickening  of  the  lining  membrane  of  the  ventricles  and  other 
changes  of  a  syphilitic  character.  The  lateral  ventricles  are  princi- 
pally and  often  solely  affected,  and  these  are  so  distended  as  to  press 
out  their  cerebral  walls,  flattening  the  convolutions,  and  turning 
them  into  a  thin  shell  often  less  than  a  quarter  of  an  inch  in  thick- 
ness. Sometimes  only  one  lateral  ventricle,  and  in  rare  cases  only 
the  fourth  ventricle,  is  affected  by  the  dropsy. 

The  diagnosis  has  to  be  made  from  rickets  and  an  acute  inflam- 
matory process.  In  rickets  the  head  is  square,  the  fontanelle  does 
not  bulge,  the  enlargement  is  less,  and  there  are  signs  of  the  disease 
in  the  bones  elsewhere. 

Prognosis. — The  congenital  cases  usually  result  fatally  in  a  few 
months,  or  at  least  before  the  third  year.  Those  developing  in  in- 
fancy may  persist  for  four  to  six  years ;  and  in  mild  cases  the  dis- 
ease ceases  toprogress  and  a  fairly  healthy  adult  life  is  reached. 

Treatment. — A  great  many  measures  have  been  recommended,  but 
there  is  no  unanimity  about  any  one  of  them.  In  such  a  state  of 
therapeutics  it  is  safe  to  say  that  treatment  is  of  little  use.  The 
most  rational  measure  is  the  inunction  of  mercury  and  the  adminis- 
tration of  iodide  of  potassium  combined  with  tonics.  Surgical 
measures,  such  as  tapping  the  ventricles,  are  irrational  and  need  not 
be  discussed.  Quincke's  method  of  tapping  the  spinal  canal  will 
not  apply  in  these  cases,  though  it  is  a  practicable  measure,  as  I 
have  found  by  experiments  or  the  cadaver.  Strapping  the  head 
with  diachylon  plaster  is  recommended  by  Trousseau  and  by  J. 
Lewis  Smith. 

Alcoholic  Meningitis  (Serous  Meningitis,  "Wet-Bbain"). 

Alcoholic  meningitis  is  a  clinical  term  \ised  to  indicate  the  pecu- 
liar group  of  cerebral  symptoms  which  is  seen  in  persons  who  have 
succumbed  to  the  effects  of  prolonged  alcoholic  intoxication.  The 
>e  is  not  a  true  meningitis  but  an  acute  toxaemia  of  the  brain 
with  serous  effusion,  and  may  be  called,  for  the  purpose  of  conven- 
ience, a  serous  meningitis. 
26 


402  DISEASES    OF   THE    NERVOUS   SYSTEM. 

Etiology. — The  disease  occurs  ofteuest  in  men  simply  because  of 
the  more  frequent  indulgence  of  the  male  sex  in  alcohol.  It  rarely 
develops  until  a  person  has  been  drinking  eight  or  ten  years,  and, 
consequently,  affects  people  oftenest  between  the  ages  of  thirty  and 
forty.  The  exciting  cause  is  commonly  alcohol  and  in  this  country 
-whiskey  or  what  are  known  as  "  hard  drinks, "  but  beer  and  ale  will 
accomplish  the  same  result.  I  have  rarely  seen  the  disease  in  wine 
drinkers.  The  persistent  use  of  morphine,  cocaine,  and  chloral  may 
lead  to  much  the  same  condition.  The  exciting  cause  is  usually  a 
continuous  drinking  bout  of  two  or  three  weeks,  ending  in  delirium 
tremens.  The  delirium  tremens,  however,  is  not  by  any  means 
always  present.  The  patient  may  pass  from  a  condition  of  pro- 
longed intoxication  into  the  condition  of  alcoholic  meningitis  or 
"wet-brain." 

Symptoms,  ^-ln  case  delirium  tremens  has  occurred,  the  patient 
after  two  or  three  days  of  prolonged  delirious  excitement  gradually 
sinks  into  a  semi-coma.  This  is  accompanied  by  a  muttering  delir- 
ium. The  patient  is  sufficiently  conscious  to  have  flitting  delusions 
and  hallucinations  of  sight  and  hearing.  At  this  time  he  is  able  to 
drink  and  take  food ;  the  pulse  is  rather  rapid,  the  temperature  is 
usually  normal  or  may  be  raised  one-half  or  one  degree.  The  skin 
is  hypereesthetic  and  pressure  upon  the  muscles  of  the  arms  or  legs 
or  abdomen  causes  pain.  The  pupils  are  usually  rather  small. 
Often  at  this  time  conjunctivitis  and  keratitis  may  appear.  After 
a  few  days  the  patient's  stupor  becomes  deeper  and  he  can  be  aroused 
only  with  difficulty.  The  arms  and  legs  are  now  somewhat  stiff, 
the  reflexes  are  exaggerated,  the  neck  is  stiff  and  slightly  retracted, 
and  attempts  to  move  it  cause  expressions  of  pain.  The  abdomen 
is  retracted  and  the  skin  and  muscles  are  still  very  hypereesthetic. 
The  lids  are  closed.  The  pupils  are  small  and  do  not  react  well  to 
light.  The  tongue  is  coated  and  usually  dry,  and  urine  and  faeces 
may  be  passed  involuntarily.  The  patient  may  linger  this  way  for 
several  days  more.  The  pulse  becomes  rapid  and  feeble,  the  ex- 
tremities are  stiff  and  cold.  The  skin  is  dry  and  loses  its  elasticity, 
so  that  when  pulled  up  between  the  fingers  it  stays  in  folds. 
"  Putty  skin"  is  a  good  name  for  this.  The  coma  deepens,  the 
temperature  may  rise  to  103°  or  104°,  and  symptoms  of  pneu- 
monia may  appear  as  the  scene  closes.  On  the  other  hand  in  some 
cases  the  patient  does  not  pass  into  the  worst  stage,  the  mind  be- 
comes clearer,  the  hyperesthesia  lessens,  food  is  taken  better,  and 
the  bowels  are  moved  voluntarily.  Improvement  continues  and  in 
three  or  four  weeks  the  convalescence  begins. 

Pathological  Anatomy. — I  have  made  autopsies  and  careful  micro- 


DISEASES   OF   THE    BRAIN    AND    ITS   MEMBRANES.  403 

scopical  examinations  in  over  twenty  cases  of  the  character  just 
described.  In  nearly  all  the  brain  is  found  to  be  somewhat  pale, 
the  arachnoid  contains  two  or  three  ounces  of  serous  fluid,  the  sub- 
arachnoid space  is  saturated  with  fluid,  and  the  ventricles  are  dilated. 
Sections  through  the  brain  sometimes  show  punctate  hemorrhages 
and  in  rare  cases  spots  of  hemorrhagic  extravasation  are  seen  sur- 
rounded by  softening.  Occasionally  the  beginning  of  a  suppurative 
cerebral  meningitis  will  be  seen.  Microscopic  examination  shows 
in  the  uncomplicated  cases  that  there  is  no  true  inflammatory  proc- 
ess. There  is  often  congestion,  but  not  always;  the  commoner 
condition  is  an  oedema  of  the  brain  tissue,  the  perivascular  and 
pericellular  spaces  being  dilated.  The  nerve  cells  show  various 
stages  of  degeneration,  not  pigmentary  in  character,  however.  The 
chromophilic  granules  are  often  unstained,  or,  if  stained,  have  lost 
their  true  relations,  and  seem  broken  down.  The  cell  outlines  are 
irregular;  the  nucleus  lies  near  the  periphery  of  the  cell,  and  in 
some  cases  has  broken  out  and  escaped  from  it.  Sometimes  there 
is  a  large  number  of  neuroglia  cells  in  the  pericellular  spaces.  The 
disease  is  undoubtedly,  primarily  at  least,  a  toxaemia  not  due  directly 
to  the  influence  of  alcohol  but  to  the  poisons  which  have  developed 
in  the  body  as  a  result  of  the  condition  of  inanition  and  the  paraly- 
sis of  the  digestive  function  caused  by  the  prolonged  ingestion  of 
alcohol  and  abstinence  from  food.  The  cell  degeneration  is  more 
like  that  which  is  known  as  "degeneration  from  a  distance,"  such 
as  is  seen  in  nerve  cells  when  the  neuraxon  is  destroyed.  It  is  a 
degeneration  which  affects  especially  the  body  of  the  cell  and  not 
so  much  the  nucleus ;  hence  the  remarkable  power  of  recovery  from 
this  condition  which  so  many  people  show. 

The  diagnosis  of  the  disease  is  to  be  made  from  ordinary  suppura- 
tive meningitis,  from  acute  serous  meningitis  due  to  infection,  and 
from  acute  encephalitis.  In  most  cases  the  history  of  the  patient 
is  quite  sufficient  to  establish  the  diagnosis.  The  symptoms  of 
themselves  are  almost  identical  with  those  of  ordinary  acute  suppu- 
rative meningitis.  The  only  distinctions  which  I  have  been  able  to 
observe  are  that  in  suppurative  meningitis  there  is  more  fever, 
there  is  less  of  the  low  delirium,  hallucinations  are  rare,  and  there  is 
an  earlier  and  more  profound  coma.  In  other  words,  it  is  an  acuter 
and  more  severe  malady  than  alcoholic  meningitis.  The  absence 
of  convulsions  and  paralysis  and  the  presence  of  hyperesthesia, 
rigidity,  and  contracted  pupils,  as  well  as  the  absence  of  pyrexia, 
are  usually  sufficient  to  distinguish  the  disorder  from  encephalitis 
or  encephalitis  complicated  by  alcoholic  meningitis. 

The  prognosis  is  bad  when  the  disease  has  become  well  developed 


404  DISEASES   OF   THE    NERVOUS   SYSTEM. 

and  when  decided  coma  and  rigidity  have  set  m.  A  prognostic 
criterium  which  I  have  long  used  and  which  is  fairly  accurate  is  this  : 
if  the  patient  has  not  a  stiff  neck  he  will  get  well,  but  when  stiff 
neck  comes  on  the  patient  dies. 

The  treatment  of  the  disorder  should  be  instituted  at  tne  very 
beginning.  If  there  are  still  any  relics  of  the  debauch,  as  shown  in 
the  condition  of  the  stomach  or  intestinal  tract,  the  stomach  should 
be  washed  out  and,  at  all  events,  a  thorough  purge  should  be  given. 
The  patient  should  then  be  fed  most  liberally  with  hot  milk  given 
every  two  hours ;  beef  tea  and  an  egg  beaten  up  in  milk  may  also 
be  given,  but  the  condition  of  practical  starvation  on  the  part  of  the 
patient  should  always  be  borne  in  mind.  Stimulants  in  the  shape 
of  whiskey  should  not  be  administered  if  it  is  possible  to  avoid  it, 
but  strychnine  in  doses  of  one-sixtieth  of  a  grain  every  two  hours 
is  often  useful.  An  ice  cap  should  be  applied  to  the  head  and  at 
times  leeches  or  large  blisters  seem  to  be  useful  applied  to  the  back 
of  the  neck.  The  patient,  however,  should  not  be  much  depleted. 
When  he  becomes  comatose  it  means  that  the  ventricles  and  arach- 
noid cavities  are  becoming  filled  with  water.  At  this  time  tapping 
the  spinal  cord  may  be  tried.  I  have  done  this  in  a  number  of 
cases  and  have  at  times  removed  two  or  three  ounces  of  fluid  with 
some  amelioration  of  the  symptoms  and  never  any  bad  results,  but 
the  measure  has  never  been  tried  early  on  promising  cases  and  I 
have  never  seen  it  do  any  permanent  good. 


CHAPTER  XIX. 

DISEASES   OF   THE   BRAD*. 

These  diseases,  like  those  of  other  parts  of  the  nervous  system, 
consist  of  malformations,  vascular  disturbances,  inflammations, 
softenings,  hemorrhages,  degenerations  and  scleroses,  chronic  infec- 
tions, tumors,  and  functional  disorders. 

Ceeebral  hyperemia  is  a  condition  in  which  there  is  an  exces- 
sive amount  of  blood  in  the  cranial  cavity;  it  may  be  acute  or 
chronic,  active  or  passive. 

Etiology. — In  the  description  which  is  to  follow  I  shall  refer  only 
to  those  conditions  of  hypersemia  of  the  brain  which  are  patholog- 
ical. It  is  a  well-recognized  fact  that  hyperaeinia  of  the  brain 
occurs  physiologically  under  excitement  and  overactivity  of  the 
heart  and  from  various  stimuli;  but  a  pathological  condition  of 
acute  congestion  may  be  induced  by  sunstroke,  certain  drugs  such 
as  alcohol,  and  by  injuries;  also  by  mechanical  causes  which  pre- 
vent the  exit  of  the  blood  from  the  cranium.  An  acute  congestion 
also  occurs  in  mania  and  in  many  forms  of  fevers,  as  well  as  in  the 
initial  stage  of  meningitis.  A  chronic  cerebral  hypersemia  may  be 
induced  by  the  causes  already  mentioned  as  bringing  on  acute  con- 
gestion. The  prolonged  use  of  alcohol,  prolonged  mental  excite- 
ment, overwork,  and  worry  may  also  lead  to  this  condition.  The 
foregoing  causes  lead  to  what  is  known  as  active  congestion,  in 
which  the  blood  is  driven  in  excess  into  the  brain  through  the 
arteries.  A  passive  congestion  may  exist  in  which  the  blood  is  pre- 
vented from  leaving  the  brain  and  is  kept  mainly  in  the  intracranial 
veins.  The  causes  of  passive  congestion  are  chiefly  mechanical, 
such  as  cardiac  disease  and  mechanical  obstructions  about  the  neck 
from  tight  clothes,  and  an  obstruction  to  the  flow  of  blood  from  the 
lungs  by  playing  on  wind  instruments. 

Symptoms. — A  great  deal  lias  been  written  regarding  the  symp- 
tomatology of  cerebral  hyperaemia,  but  many  of  the  statements 
made  are  nothing  but  guesswork.  Probably  the  main  symptoms 
produced  by  an  active  congestion  of  the  brain  are  a  sense  of  fulness 


4(H)  DISEASES   OF   THE    NERVOUS    SYSTEM. 

and  pressure,  a  feeling  of  constriction  about  the  head,  some  head- 
ache which  may  be  vertical,  mental  excitement  or  irritability,  con- 
fusion of  ideas,  vertigo,  insomnia,  ringing  in  the  ears,  and  pulsating 
sounds  in  the  head.  These  symptoms  are  sometimes  increased  when 
the  patient  lies  down,  and  are  generally  increased  when  the  patient 
bends  the  head  over  so  as  to  prevent  the  return  flow  of  blood  from 
the  brain.  It  is  impossible  to  diagnosticate  passive  hyperemia 
from  active  through  the  symptoms  alone,  but  probably  in  the  former 
condition  the  disturbances  and  symptoms  mentioned  are  less 
marked ;  in  other  words,  an  active  hyperaemia  produces  more  phe- 
nomena than  passive.  In  either  case  examinations  of  the  fundus 
of  the  eye  and  of  the  tympanum  furnish  no  sure  criteria. 

Pathology. — Cerebral  hyperaemia  used  to  be  regarded  as  nearly 
synonymous  with  cerebral  neurasthenia.  In  the  writer's  opinion, 
it  is  secondary  to  the  neurasthenic  state,  and  is  produced,  if  it  exists 
in  that  state,  by  the  impaired  vasomotor  innervation  which  is  char- 
acteristic of  neurasthenia.  It  is  not  wise,  therefore,  to  make  the 
diagnosis  of  cerebral  hyperaemia  often  as  the  primary  condition. 
It  is  only  after  traumatisms  and  sunstroke  or  after  a  meningitis  that 
we  can  speak  of  the  cerebral  hyperaemia  as  being  in  a  certain  sense 
the  primary  condition  to  be  treated.  The  statement  made  by  some 
writers  that  cerebral  hyperaemia  underlies  certain  conditions  of 
acute  delirium,  of  aphasia,  of  paralysis,  and  even  dementia  or  in- 
sanity can  hardly  be  supported.  In  many  of  the  cases  of  cerebral 
hyperaemia,  in  which  symptoms  are  produced,  there  is  undoubtedly 
a  condition  of  toxaemia  which  is  a  contributing  factor  to  most  of  the 
symptoms. 

Treatment. — The  specific  treatment  of  cerebral  hyperaemia,  when 
indicated,  consists  in  giving  large  doses  of  fluid  extract  of  ergot 
and  bromide  of  potassium.  One  or  two  drachms  of  the  ergot  three 
times  a  day  and  fifteen  or  twenty  grains  of  bromide  of  potassium 
may  be  prescribed.  Wet  cups  to  the  back  of  the  neck,  the  cautery 
in  the  same  region,  ice  caps,  purgatives,  quiet  and  rest,  and  a  care- 
ful regulation  of  the  diet  and  the  bowels  are  all  important  measures. 

Cerebral  Anaemia. — This  condition,  like  hyperaemia,  may  be 
either  acute  or  chronic. 

It  occurs  among  the  young ;  more  often  in  females  than  in  males. 
It  is  seen  in  early  adult  life,  when  it  is  induced  by  the  various 
causes  producing  general  anaemia,  and  again  after  the  climacteric, 
when  it  is  due  to  organic  changes  in  the  cerebral  arteries  of  the 
nature  of  an  obliterating  endarteritis.  Bright' s  disease  and  syph- 
ilis, exhausting  diseases  and  profuse  hemorrhages,  and  such  dis- 
orders of  digestion  and  nutrition  as  lead  to  general  anaemia  produce 


DISEASES   OF   THE    BRAIN.  407 

also  cerebral  anaemia.     A  potent  cause  of  acute  cerebral  anaemia  is 
fright. 

Symptoms. — The  symptoms  of  acute  cerebral  anseinia  are  vertigo, 
confusion  of  ideas,  nausea,  faintness,  or  complete  syncope.  In 
chronic  cerebral  anaemia  the  symptoms  are  mental  apathy  and  a 
feeling  of  disinclination  to  work,  tendency  to  somnolence  in  the 
daytime  and  insomnia  at  night,  mental  depression,  headaches  which 
are  usually  frontal  or  vertical,  occasionally  some  vertigo  and  tinni- 
tus. There  may  be  spots  before  the  eyes  and  undue  sensitiveness 
to  sounds.  In  children  some  very  severe  symptoms  are  attributed 
to  cerebral  anaemia,  but  here,  as  in  hyperaemia,  it  is  probable  that 
there  are  other  causes  at  work,  particularly  toxic  agents  or  reflex 
disturbances. 

Diagnosis. — A  chronic  anaemia  of  the  brain  can  hardly  be  recog- 
nized except  through  the  evidences  of  a  general  anaemia.  When 
this  is  present  and  there  are  also  symptoms  such  as  have  been  de- 
scribed, a  fairly  certain  diagnosis  can  be  made.  We  must  look 
upon  cerebral  anaemia  as  being  in  almost  all  cases  a  secondary  phe- 
nomenon, except  in  the  aged,  and  then  the  trouble  is  due  not  alone 
to  poverty  of  the  blood,  but  to  the  fact  that  the  circulatory  appa- 
ratus is  diseased.  It  is  generally  believed  that  in  cerebral  anaemia, 
the  symptoms  improve  somewhat  by  the  horizontal  position  and  are- 
made  worse  by  the  upright  position.  It  is  also  asserted  that  iru 
anaemia  the  pupils  rather  tend  to  be  dilated,  while  in  hyperaemia 
they  are  contracted. 

Treatment.  — Treatment  should  be  directed  toward  enriching  the 
supply  of  blood  and  toward  improving  the  general  nutrition.  It 
consists,  therefore,  in  the  administration  of  preparations  of  iron 
and  of  such  tonics  as  the  mineral  acids,  strychnine,  quinine,  and 
nitroglycerin. 

INFLAMMATION  OF  THE  BRAIN. 

The  forms  of  acute  inflammation  of  the  brain  are  acute  suppura- 
tive encephalitis  or  brain  abscess,  acute  exudative  encephalitis  with 
hemorrhage,  and  acute  polio-encephalitis.  The  only  important  form 
of  chronic  inflammation  is  multiple  sclerosis. 

Acute  Suppubatiye  Encephalitis  (Abscess  of  the  Brain). 

Brain  abscess  is  a  suppurative  inflammation  which  affects  the 
parenchymatous  and  other  structures  of  the  organ.  It  is  always  a. 
focal  disease,  but  may  be  single  or  multiple. 


408  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Etiology. — The  primary  cause  of  all  forms  of  brain  abscess  is  a 
microbic  infection.  The  form  of  microbe,  its  mode  of  entrance,  and 
the  part  of  the  brain  attacked  vary  greatly.  The  predisposing 
causes  relate  chiefly  to  age  and  sex.  Brain  abscess  rarely  occurs 
before  the  first  year  or  after  the  fiftieth  year  of  life.  It  is  rather 
frequent  in  young  people,  and  occurs  on  the  whole  oftenest  between 
the  ages  of  ten  and  thirty.  Males  are  more  often  affected  than 
females  in  the  ratio  of  about  three  to  one.  The  exciting  causes 
are  chiefly  disease  of  the  ear,  of  the  nose,  and  of  the  cranial 
bones,  injuries,  and  remote  suppurative  processes.*  To  this  may 
be  added  infectious  fevers  and  the  presence  of  tumors.  Chronic 
inflammation  of  the  middle  and  internal  ear  is  the  most  common 
cause  of  brain  abscess,  especially  when  that  disease  affects  the 
tympanum  and  mastoid  cells.  Caries  of  the  ethmoid  and  nasal 
bones  and  of  the  orbital  cavity  leads  to  brain  abscesses  in  a  consid- 
erable proportion  of  cases.  After  chronic  ear  and  bone  diseases  in- 
juries are  the  most  frequent  cause.  The  injury  may  be  a  compound 
fracture  with  direct  infection  from  the  open  wound,  or  the  abscess 
may  be  the  result  of  oontrecowp  and  may  develop  in  a  part  of  the 
brain  opposite  to  that  which  was  injured,  or  the  abscess  may  develop 
below  the  point  injured,  there  being  apparently  healthy  tissue  be- 
tween the  surface  of  the  brain  and  the  diseased  part.  These  ab- 
scesses develop  through  laceration  of  brain  tissue  and  subsequent 
infection  of  the  wound  with  organisms.  The  most  common  remote 
suppurative  processes  which  are  followed  by  brain  abscess  are  tuber- 
culous inflammation  of  the  lungs,  fetid  bronchitis,  and  empyema. 
Brain  abscess  may  develop,  however,  from  distant  points  of  suppu- 
ration on  the  extremities  or  in  almost  any  part  of  the  body.  Pye- 
mia may  lead  to  the  production  of  brain  abscess.  Among  the 
infectious  fevers  which  are  complicated  with  brain  abscess  are 
diphtheria,  typhoid  and  typhus  fevers,  erysipelas,  small-pox,  the 
grippe.  The  oidium  albicans  or  thrush  may  also  be  a  cause. 
Brain  tumors  sometimes  become  surrounded  by  a  suppurative  en- 
cephalitis or  may  break  down  with  the  formation  of  mixed  suppura- 
tive and  neoplastic  tissue.  Tuberculous  tumors  are  most  frequently 
accompanied  by  suppurative  encephalitis. 

Symptoms.  — Brain  abscesses  take  sometimes  an  acute  and  some- 
times a  chronic  course.  In  acute  cases  the  symptoms  develop  rap- 
idly and  the  disease  runs  its  course  in  a  few  days  or  weeks.  The 
symptoms  come  under  the  general  head  of  those  of  pressure,  those 

*  In  nine  thousand  consecutive  autopsies  at  Guy's  Hospital  there  were 
fifty-seven  brain  abscesses  due  to  ear  disease  and  one  due  to  nasal  disease 
(Pitt). 


DISEASES   OF  THE    BRAIN.  409 

of  poisoning  from  the  diseased  focus,  and  local  symptoms  due  to 
irritation  or  destruction  of  certain  special  areas  of  the  brain.  The 
pressure  symptoms  are  those  of  headache  which  is  often  very  severe 
ami  persistent,  vomiting  which  is  quite  frequent  though  not  invari- 
able, vertigo,  and  a  condition  of  mental  dulness  which  may  pass 
into  a  delirium  ending  finally  in  coma.  Optic  neuritis  often  occurs. 
The  pupils  are  apt  to  be  irregular,  but  furnish  no  definite  indica- 
tions. The  pulse  is  usually  slow,  ranging  from  60  to  70,  but  it 
varies  a  great  deal.  The  temperature  is  normal  or  subnormal  as  a 
rule,  but  this  also  varies,  and  it  may  rise  several  degrees  above 
normal,  always  running  an  irregular  course.  The  toxic  symptoms 
are  those  which  we  get  in  septic  poisoning;  namely,  prostration, 
irregular  fever,  emaciation,  anorexia,  and  such  meutal  and  sensory 
disturbances  as  have  already  been  referred  to.  As  a  result  of  local 
irritation  or  destruction,  there  occur  convulsions,  paralysis,  aphasia, 
and  disorders  of  some  of  the  special  senses.  Convulsions  are  not 
very  common.  When  they  occur  they  are  generally  of  an  epileptic 
character.  The  paralysis  is  usually  in  the  form  of  hemiplegia. 
The  cranial  nerves  are  not  often  involved,  if  we  except  the  optic. 
The  urine  is  said  to  show  a  diminution  in  chlorides  and  an  increase 
in  phosphates.     The  patient  dies  finally  in  coma  from  exhaustion. 

In  the  chronic  form  of  brain  abscess  the  symptoms  may  for 
weeks,  months,  or  years  remain  practically  latent,  after  the  exciting 
cause  has  been  at  work  and  after  the  abscess  has  been  established. 
The  patient  during  this  latent  stage  may  suffer  from  headache,  ver- 
tigo, mental  irritability,  and  depression;  he  may  at  times  have  a 
convulsive  attack.  Occasionally  there  will  be  an  exacerbation  of 
the  disease,  at  which  time  he  suffers  from  intense  pain,  vomiting, 
perhaps  delirium  or  a  convulsion.  From  this  he  recovers  and  con- 
tinues in  a  fairly  good  state  of  health  again.  After  a  variable 
period,  usually  of  weeks  or  months,  the  terminal  stage  sets  in. 
This  terminal  stage  of  the  chronic  form  may  assume  very  much  the 
characters  of  the  acute  form  already  described.  In  other  cases  it 
shows  itself  by  a  sudden  apoplectic  or  epileptic  seizure  or  a  sudden 
attack  of  coma,  in  which  the  patient  sinks  and  rapidly  dies.  These 
terminal  phenomena  are  due  to  the  fact  that  the  abscess,  which  has 
been  previously  encysted  and  quiescent,  suddenly  breaks  into  a 
lateral  ventricle  or  through  the  surface  of  the  brain,  or  to  the  fact 
that  a  hemorrhage  occurs  into  the  abscess. 

Complications. — The  common  complications  of  brain  abscess 
are  a  phlebitis  of  the  superior  petrosal  and  lateral  sinuses  and  a 
meningitis.  The  phlebitis  rcoompames  abscesses  that  are  caused 
by  disease  of  the  ear.     The  meningitis  may  be  caused  by  ear  dis- 


410  DISEASES   OF   THE   NERVOUS   SYSTEM. 

ease,  but  more  frequently  accompanies  abscesses  due  to  injury. 
When  phlebitis  is  present  there  will  be  found  an  oedema  about  the 
ear  and  neck  and  a  hardness  of  the  jugular  veins.  In  meningitis 
there  is  apt  to  be  more  rigidity  of  the  neck,  more  pain,  and  there 
are  often  cranial-nerve  paralyses. 

Pathology.- — Acute  suppurative  encephalitis  resembles  acute 
suppurative  myelitis  in  the  intimate  nature  of  the  changes  that  take 
place.  There  is  an  intense  congestion  of  the  parts,  which  gives  it 
a  reddened  appearance  and  which  used  to  give  to  this  process  the 
name  of  red  softening.  This  condition,  however,  is  only  the  initial 
stage  of  the  suppurative  inflammation  and  does  not  deserve  to  be 
ranked  as  a  special  form  of  inflammatory  process.  It  ijS  possible 
that  in  some  cases  the  inflammation  may  get  no  farther  than  the 
stage  of  red  softening.  The  congestion  then  gradually  disappears, 
absorption  of  exudate  occurs,  and  a  more  or  less  complete  recovery 
takes  place.  When  the  process  continues,  however,  the  parts  be- 
come crowded  with  leucocytes  and  infiltrated  with  inflammatory 
exudate.  The  nerve  fibres  and  cells  are  destroyed,  in  part  mechan- 
ically, in  part  by  the  poisonous  influence  of  the  pyogenic  organisms. 
The  nerve  cells  lose  their  normal  contours,  swell  up,  and  disinte- 
grate; the  neuroglia  cells  absorb  the  broken-down  detritus  and 
swell  up,  forming  what  are  known  as  granular  corpuscles;  the 
leucocytes  increase  until  a  purulent  mass  is  formed.  The  total  re- 
sult is  a  mixture  of  broken-down  nerve  fibres  and  cells,  leucocytes, 
and  granular  bodies.  Bacteriological  tests  show  the  presence  of 
various  pyogenic  microbes.  The  abscess  thus  formed  varies  in  size 
from  one  centimetre  to  six  or  eight  centimetres  in  diameter  (two- 
fifths  of  an  inch  to  three  inches).  It  is  generally  somewhat  round, 
and  if  the  case  is  chronic  a  fibrous  wall  is  formed.  It  takes  from 
three  to  four  weeks  for  such  a  wall  to  develop  (Fig.  203).  Brain 
abscesses  are  usually  single,  occasionally  there  are  two  or  three.  In 
some  conditions  they  are  multiple;  that  is  to  say,  there  may  be 
fifteen,  twenty,  or  more.  Multiple  brain  abscesses  are  always  small 
and  are  usually  due  to  pysemic  infection. 

Locution. — Brain  abscesses  involve  the  cerebrum  oftener  than  the 
cerebellum,  in  the  proportion  of  about  four  to  one  (Barr) .  They 
occur  rather  oftener  in  the  right  cerebrum.  They  are  very  rare  in 
the  pons  and  medulla.  The  cerebral  lobes  oftenest  affected  are  the 
temporal  and  frontal.  In  the  cerebellum  it  is  the  lateral  hemi- 
spheres that  are  most  frequently  attacked.  The  seat  of  the  abscess 
has  important  relations  to  the  cause.  Abscesses  due  to  ear  disease 
are  almost  always  either  in  the  temporal  lobe  or  in  the  cerebellum. 
If  the  ear  disease  is  in  the  tympanum,  the  cerebrum  is  usually  the 


DISEASES    OF   THE    BRAIN. 


411 


seat  of  the  abscess.  If  the  disease  is  in  the  mastoid  cells,  the  cere- 
bellum is  usually  the  part  affected.  If  the  disease  is  in  the  laby- 
rinth, the  abscess  is  also  more  apt  to  be  in  the  cerebellum.  This 
distribution  of  the  seat  of  the  disease  is  due  to  the  anatomical  rela- 
tions of  the  bony  parts  to  the  temporal  lobe  and  cerebellum,  respec- 
tively. Brain  abscesses  due  to  injuries  are  more  frequent  in  the 
frontal  and  temporal  lobes.  What  are  known  as  idiopathic  brain 
abscesses — that  is,  those  which  arise  without  any  known  cause — are 


Fig.  303. — Abscess  op  Cerebellum. 


most  frequent  in  the  frontal  lobes.  This  is  because  most  such  cases 
are  due  to  an  unrecognized  affection  of  the  nasal  cavities  and 
ethmoid  bone.  Brain  abscesses  due  to  suppurative  processes  in  the 
lungs  and  pleura  are  probably  embolic;  and,  as  the  emboli  are  car- 
ried up  into  the  middle  cerebral  artery,  the  brain  abscesses  having 
this  origin  are  situated  in  the  field  supplied  by  this  artery.  In 
children  under  ten,  in  whom  brain  abscess  is  usually  due  to  ear 
disease,  the  cerebellum  is  more  apt  to  be  affected. 

Course. — Acute  abscesses  last  from  five  to  fourteen  days,  rarely 
over  thirty  days.  Traumatic  cases  run  the  shortest  course. 
Chronic  abscesses  may  have  a  latent  period  of  weeks,  months,  and 
in  rare  cases  even  one  or  two  years.  When  terminal  symptoms 
come  on  death  occurs  in  a  few  days.     In  a  few  cases  brain  abscesses 


412 


DISEASES   OF   THE   NERVOUS    SYSTEM. 


have  been  spontaneously  evacuated  through  the  nose.  Aside  from 
this,  the  termination  is  always  a  fatal  one  unless  surgical  interfer- 
ence takes  place.  There  is  sometimes  a  recurrence  of  the  abscess 
after  an  operation. 

Diagnosis. — The  diagnosis  of  brain  abscess  is  based  upon  the 
history  of  injury,  aural  or  nasal  disease,  remote  suppuration,  upon 
the  general  symptoms  of  sepsis,  upon  the  presence  of  headache, 
vomiting,  slow  pulse,  normal  or  subnormal  and  irregular  tempera- 
ture, a  local  tenderness  of  the  scalp  and  rise  of  temperature  over 


Fig.  204.— Showing  the  Points  where  the  Trephine   is  Usually  Applied  and  the  Re- 
lations op  the  Sinus.    The  divisions  on  the  lines  indicate  quarter-inches  (LanceO. 

the  seat  of  the  lesion,  hebetude,  delirium,  optic  neuritis,  rapid  wast- 
ing, and  diminution  of  chlorides  in  the  urine. 

The  diagnosis  of  the  location  of  the  abscess  is  based  upon  the 
history  of  its  cause,  whether  from  injury,  ear  disease,  emboli  from 
the  lungs,  or  nasal  disease ;  also  upon  the  presence  of  hemiplegia, 
local  convulsions,  tenderness  and  rise  of  temperature  of  a  certain 
area  of  the  scalp.  As  brain  abscesses  are  apt  to  affect  latent  regions 
like  the  temporal  and  frontal  lobes,  local  diagnosis  is  usually  diffi- 
cult. The  diagnosis  must  be  made  from  tumors  of  the  brain,  men- 
ingitis, and  phlebitis  of  the  sinuses.  The  differential  points  are 
given  under  the  heads  of  the  diseases  mentioned.  The  presence  of 
leucocytosis  helps  in  distinguishing  the  presence  of  suppuration. 

The  prognosis  of  the  disease  is  absolutely  unfavorable  unless 
some  surgical  interference  is  resorted  to.  The  few  rare  cases  of 
spontaneous  evacuation  of  the  abscess  would  not  lead  to  any  prac- 
tical modification  of  this  statement. 


DISEASES    OF    THE    BRAIN.  413 

Treatment. — The  actual  treatment  of  a  brain  abscess  after  it  has 
developed  is,  as  already  stated,  exclusively  a  surgical  one.  The 
successes  so  far  have  not  been  very  great,  but  they  have  been  suffi- 
cient to  justify  operation  and  to  furnish  greater  hope  for  the  future, 
when  a  more  exact  diagnosis  can  be  made  and  a  wider  surgical  ex- 
perience has  been  obtained.  The  accompanying  figure  shows  the 
points  to  be  located  in  trephining  for  abscess  from  ear  disease. 
Something  is  due  to  the  patient  in  the  way  of  prevention,  especially 
in  cases  of  persons  who  have  chronic  aural  or  nasal  disease  with 
carious  processes.     These  should  be  carefully  watched  and  treated. 

Acute    Exudative    Encephalitis    of    the    Gray   Matter 
(polio-excephalitis) . 

Acute  exudative  polio-encephalitis  is  a  disease  which  affects  the 
gray  matter  forming  the  cranial  nerve  nuclei.  It  has  two  forms, 
polio-encephalitis  superior,  and  inferior. 

Acute  polio-encephalitis  inferior  is  a  disease  which  is  strictly 
analogous  in  course  to  acute  polio-myelitis.  The  special  symptoms 
simply  depend  upon  the  peculiar  location  of  the  disease.  They  con- 
sist of  an  acute  glosso-labio-laryngeal  palsy,  and  are  referred  to 
under  the  description  of  bulbar  paralysis. 

Acute  polio-encephalitis  superior  is  a  disease  in  which  the  nuclei 
of  the  nerves  supplying  the  eye  muscles  are  involved ;  it  is  also  a 
disease  analogous  to  polio-myelitis  anterior,  and  has  been  described 
under  the  head  of  ophthalmoplegia. 

Acute  cortical  polio-encephalitis  of  children  is  a  disease  which, 
according  to  Striimpell,  involves  the  gray  matter  of  the  convexity  of 
one  of  the  cerebral  hemispheres.  It  also  is  supposed  to  be  strictly 
analogous  to  an  inflammation  of  the  anterior  horns  of  the  spinal 
cord.     The  real  existence  of  this  disease  is  still  doubtful. 

A<  i  11:   Exudative   Encephalitis   with   Hemorrhage   (Hemor- 
rhagic Encephalitis). 

This  is  a  form  of  encephalitis  affecting  diffusely  various  areas  of 
the  brain  and  characterized  by  intense  congestion  with  capillary 
hemorrhages  followed  by  inflammation,  never  ending  in  suppuration 
and  sometimes  terminating  in  partial  or  complete  recovery. 

Etiology. — One  of  the  principal  exciting  causes  of  this  disease 
is  probably  the  infection  <>f  influenza,  but  it  also  occurs  in  connec- 
tion with  other  infectious  fevers,  such  as  typhoid,  typhus,  and  epi- 
demic cerebro-spinal  meningitis.  It  lias  been  known  to  follow 
malignant  endocarditis  and  it  occurs  in  connection  with  the  puer- 


414  DISEASES   OF   THE    NERVOUS   SYSTEM. 

peral  state.  I  have  seen  a  number  of  cases  occurring  as  a  result  of 
acute  alcoholism,  although  it  is  not  impossible  that  there  is  a  coin- 
cident infection.  In  about  one  out  of  ten  autopsies  on  the  brain  of 
persons  who  have  died  from  acute  alcoholism,  I  have  found  large 
foci  of  hemorrhagic  softening  with  evidence  of  inflammatory  reac- 
tion about  it.  The  disease  occurs  also  after  sunstroke.  Acute 
hemorrhagic  encephalitis,  when  due  to  infection,  occurs  most  fre- 
quently in  the  young,  that  is  to  say,  in  persons  under  twenty,  and 
more  often  in  females  than  in  males.  Probably  the  increased  sus- 
ceptibility of  the  young  to  the  infectious  fevers  is  the  explanation 
of  this. 

Symptoms. — The  disease  begins  rather  suddenly  and  without 
notable  premonitory  symptoms.  The  patient  is  seized  by  head- 
ache followed  by  fever  sometimes  reaching  105°  F.  This  may  be 
associated  with  vertigo,  vomiting,  photophobia,  and  delirium.  The 
symptoms  of  irritation  disappear  and  are  followed  by  a  condition  of 
semicoma  or  stupor.  The  patient  can  generally  be  partly  aroused, 
and  he  does  not  have  the  stiff  neck  or  the  small  pupils  of  menin- 
gitis. The  respirations  are  shallow  and  frequent,  the  pulse  is 
rapid  and  feeble.  As  the  disease  progresses,  the  deep  reflexes  are 
diminished  and  later  the  sphincters  may  be  involved.  After  the 
patient  has  lain  in  a  semicomatose  condition  for  several  days,  he 
may  become  less  stupid  and  more  irritable  and  restless;  or  after- 
two  or  three  weeks  of  comparative  stupor  he  may  begin  gradually 
to  improve  and,  in  a  few  weeks  more,  convalescence  takes  place. 

In  some  cases  an  epileptic  convulsion  may  occur  in  the  early 
part  of  the  disease.  Again,  as  the  disease  develops,  aphasia  and 
paralysis  of  the  arm  or  leg,  or  hemiplegia,  may  appear.  In  accord- 
ance with  the  location  of  the  inflammation,  the  patient  may  have 
disturbances  in  the  motor  sphere,  or  he  may  have  hemianopsia, 
hemiataxia,  or  disturbance  of  the  cranial  nerves,  such  as  nystagmus, 
or  eye  palsy,  or  difficulty  in  speech  and  deglutition.  An  optic  neu- 
ritis may  also  occur. 

Course  and  Prognosis. — The  disease  is  always  serious  but  is  not 
by  any  means  always  fatal.  It  may  in  its  milder  form  run  a  course 
of  two  or  three  weeks,  the  patient  gradually  coming  out  of  his 
stupor  and  making  a  slow  recovery.  In  other  cases  the  coma  con- 
tinues to  deepen  and  the  patient  dies  of  exhaustion,  and  in  still 
other  cases  the  disease  passes  into  a  chronic  state  in  which  he 
lingers  for  weeks  and  even  months. 

Diagnosis. — The  disease  in  the  young  is  probably  more  often 
mistaken  for  meningitis.'  It  is  to  be  differentiated  from  this  by  the 
sudden  onset  with  coma,  the  absence  of  projectile  vomiting,  pin- 


DISEASES    OF   THE    BRADST.  "±15 

hole  pupils,  stiff  neck,  hyperesthesia,  and  rigidity  of  the  limbs. 
The  presence  of  hemiplegia  or  local  paralysis,  or  the  occurrence  of 
an  epileptoid  attack,  would  point  to  encephalitis.  The  diagnosis 
from  meningitis,  however,  cannot  always  be  made.  The  previous 
occurrence  of  an  attack  of  grippe  in  the  young,  or  of  exposure  to  the 
sun  or  acute  alcoholism  in  the  adult,  would  lead  to  the  probability 
of  an  encephalitis,  provided  the  symptoms  of  meningeal  irritation 
could  be  excluded.  Tuberculous  meningitis  can  be  excluded  usually 
by  the  presence  of  premonitory  symptoms  and  the  absence  of  any 
tuberculous  focus  in  the  lungs  or  intestines.  By  the  help  of  lumbar 
puncture  fluid  can  be  withdrawn  from  the  spinal  sac,  and  examina- 
tion of  it  might  be  of  service  in  excluding  at  least  tuberculous  men- 
ingitis or  a  serous  meningitis. 

Pathological  Anatomy. — The  pathological  process  underlying 
this  disease  consists  of  an  acute  inflammation  with  intense  conges- 
tion and  numerous  small  hemorrhages  and  capillary  emboli.  There 
is  some  hemorrhagic  exudation  as  well  as  infiltration  of  leucocytes, 
with  a  certain  amount  of  softening  of  the  cerebral  tissue  in  the 
neighborhood.  The  parts  most  frequently  affected  are  the  semi- 
ovale,  the  temporal  lobes,  the  base  of  the  brain,  and  the  corpus 
striatum.  In  four  cases  which  I  have  examined,  the  process  was  in 
the  temporal  lobes,  the  parietal  lobule,  the  mid-brain,  and  the 
corpus  striatum.  If  the  process  is  a  mild  one,  the  hemorrhage  and 
exudate  are  absorbed,  and  the  injured  brain  tissue  is  gradually  re- 
placed by  connective  and  neuroglia  tissue.  In  this  way  small  foci 
of  sclerotic  tissue  are  formed  and  the  patient  may  afterward  suffer 
from  symptoms  due  to  this  condition.  In  the  severer  cases  the  soft- 
ening becomes  more  extensive,  larger  hemorrhages  occur,  and  in  one 
case  I  have  seen  a  massive  apoplexy  as  the  terminal  stage. 

Treatment. — The  patient  should  be  kept  quietly  in  bed  and  should 
be  given  an  active  purge.  Calomel  is  usually  employed,  but  croton 
oil  has  seemed  to  me  to  be  much  more  efficient  as  an  eliminative  and 
counter-irritant.  The  kidneys  should  be  kept  active,  an  ice  cap 
placed  upon  the  head,  and  leeches  placed  at  the  back  of  the  neck. 
The  treatment  after  this  can  be  only  that  of  sedation  and  support. 
If  the  patient  is  stuporous,  and  has  a  high  fever,  small  doses  of 
aconite  should  be  given.  If  he  is  asthenic,  he  should  receive  strych- 
nine. Of  course,  the  nourishment  should  be  carefully  attended  to, 
and,  if  he  suffers  pain,  he  should  have  morphine.  Chloral  and 
bromide  seem  to  be  the  most  efficient  agents  for  relieving  the  rest- 
lessness and  insomnia. 


416      •  diseases  of  the  nervous  system. 

Multiple   Sclerosis. 

Multiple  sclerosis  is  a  chronic  and  progressive  malady  charac- 
terized by  some  paralysis,  usually  in  the  form  of  paraplegia,  by 
coarse  tremor,  disturbances  of  speech,  nystagmus,  apoplectiform 
attacks,  and  various  other  cerebral  and  spinal  symptoms  depending 
upon  the  seat  of  the  lesion.  It  is  due  to  the  development  of  sclerotic 
patches  in  the  different  parts  of  the  brain  and  cord,  which  patches 
are  for  the  most  part  the  result  of  a  neuroglia  proliferation.  The 
disease  is  probably  an  inflammatory  rather  than  a  degenerative  one. 
It  affects  the  spinal  cord  as  well  as  the  brain. 

Et hih)< hi. — It  occurs  rather  more  frequently  in  the  male  sex  and 
is  a  disease  of  the  first  half  of  life.  Multiple  sclerosis  is  in  fact 
one  of  the  few  chronic  nervous  disorders  of  organic  origin  develop- 
ing at  this  time.  Most  cases  begin  between  the  age  of  twenty  and 
thirty.  Cases  have,  however,  been  observed  in  infants  and  chil- 
dren, but  the  trouble  in  its  typical  form  does  not  appear  in  the  de- 
clining years  of  life.  The  sufferers  have  often  inherited  a  feeble 
power  of  resistance  on  the  part  of  the  central  nervous  system.  But 
the  disease  is  not  directly  hereditary.  There  can  be  no  doubt  that 
the  most  important  of  all  of  the  few  causes  of  multiple  sclerosis  is 
infection.  This  is  so  true  that  it  may  be  called  a  post-infectious 
disease.  The  infectious  disorders  which  are  followed  by  sclerosis 
are  typhoid  fever,  pneumonia,  malaria,  and  the  eruptive  fevers. 
Among  these  malaria  and  typhoid  are  the  more  important.  It  has 
been  known  to  follow  also  diphtheria,  whooping-cough,  erysipelas, 
dysentery,  cholera,  and  even  rheumatism.  Besides  infection,  trauma 
and  shock  are  rarer  causes,  and  a  malady  somewhat  resembling 
multiple  sclerosis  may  follow  sunstroke.      Syphilis  is  rarely  a  cause. 

Symptoms. — The  disease  begins  insidiously.  A.  comparatively 
short  time  after  recovery  from  malaria  or  some  acute  fever,  the 
patient  begins  to  suffer  from  Aveakness  of  the  lower  limbs  with  stiff- 
ness and  some  degree  of  numbness.  The  bladder  is  also  a  little 
weak,  and  it  is  difficult  to  retain  the  urine.  In  fine,  the  symptoms 
are  very  much  like  those  of  the  onset  of  myelitis.  Very  soon  the 
patient  notices  some  unsteadiness  in  the  gait,  due  not  alone  to  weak- 
ness in  the  legs  but  to  a  certain  degree  of  ataxia.  He  finds  also 
that  his  hands  are  trembling  and  that  this  tremor  increases  upon 
voluntary  motion.  It  is  the  type  of  tremor  known  as  "  intentional." 
He  has  at  this  time  also  some  indistinctness  in  speech,  it  being 
difficult  for  him  to  enunciate  long  words.  These  come  out  in  a  slow, 
syllabic  utterance,  as  it  is  called,  each  syllable  being  spoken  sepa- 
rately.    He  may  have  also  a  little  trouble  in  swallowing.     By  this 


DISEASES   OF   THE   BRAIN.  417 

time  he  has  had  some  sensation  of  numbness  in  the  limbs,  and  some 
pains  occasionally  in  the  joints  and  extremities,  but  the  sensory 
troubles  are  not  very  marked.  If  he  is  examined  by  a  physician  three 
or  four  months  after  the  beginning  of  the  malady,  it  will  be  found 
that  the  gait  is  stiff  and  awkward,  the  patient  walking  somewhat  like  a 
drunken  man ;  or,  in  other  cases,  it  may  simply  be  the  stiff,  weak  gait 
of  moderate  paraplegia.  The  Romberg  symptom  will  be  found  to  be 
present  to  some  extent.  The  knee  jerks  are  exaggerated  and  ankle 
clonus  may  be  present.  The  hands  are  unsteady,  and  the  movements 
are  characterized  by  a  jerky  tremor,  which  may  be  so  great  that  the 
patient  has  difficulty  in  dressing  and  feeding  himself.  This  tremor 
disappears  almost  entirely  if  the  patient  lies  flat  upou  his  back.  If 
he  sits  up,  however,  it  may  be  seen  perhaps  in  the  muscles  cf  the  neck, 
causing  the  head  to  be  oscillated,  and  constant,  more  or  less  regular 
tremor  in  the  arms  is  present.  The  speech  is  thick  and  slow,  and 
often  almost  unintelligible  in  the  severer  cases.  Examination  of  the 
eyes  shows  a  nystagmus,  perhaps,  only  when  the  eyes  are  turned  to 
one  side,  but  often  the  jerky  movements  are  seen,  even  when  the  pa- 
tient is  told  to  look  directly  at  an  object.  The  tongue  is  protruded 
in  a  jerky  way,  and  attempts  at  swallowing  are  often  awkward.  If 
a  glass  of  water  is  handed  him,  the  patient  seizes  it,  but  in  carrying 
it  to  his  mouth  he  agitates  it  so  violently  that  the  fluid  is  spilled 
and  perhaps  the  tumbler  drops  from  his  hands.  Examination  of 
the  muscular  system  shows  some  weakness  of  the  legs  or  possibly 
some  degree  of  hemiplegia.  There  is,  however,  no  marked  atrophy 
of  the  limbs,  and  no  change  of  any  moment  in  the  electrical  reac- 
tions. Examination  of  the  cutaneous  sense  may  show  some  little 
tactile  anaesthesia  in  the  limbs,  but  this  is  not  always  present. 
There  is  a  certain  amount  of  ataxia,  which  is  not  so  much  due  to 
the  muscular  anaesthesia  as  to  inability  to  control  and  co-ordinate 
the  movements.  There  is  no  loss  of  sense  of  weight,  or  of  pressure. 
Of  the  nerves  of  special  sense  the  eye  is  most  frequently  involved. 
The  patient  may  have  some  diplopia  from  paralysis  of  one  of  the 
eve  muscles.  The  pupils  react  to  light  and  accommodation.  Ex- 
amination of  the  fundus  of  the  eye  shows  a  certain  amount  of 
atrophy  of  the  optic  disc  in  the  temporal  half,  a  characteristic  con- 
dition in  this  disease.  In  later  stages  this  may  go  on  to  complete  and 
general  atrophy  of  the  nerve.  On  account  of  this  involvement  of 
the  optic  nerve,  the  patient  suffers  from  contraction  of  the  visual 
field,  scintillating  scotomata,  ami  weakness  of  vision. 

Sometimes  he  develops  the  above  s\  mptoms  to  only  a  moderate 
extent  a  short  time  after  the  infectious  fever.  He  then  gradually 
improves  and  gets  nearly  well.     Some  traces  of  the  malady,  how- 

-r, 


418  DISEASES   OF   THE    NERVOUS   SYSTEM. 

ever,  still  linger.  After  a  number  of  years  it  begins  to  develop 
again,  and  it  then  progresses  steadily.  Thus  an  examination  of  the 
history  of  a  case  in  which  the  disease  apparently  began  well  along 
in  adult  life  will  show  that  the  beginning  of  the  trouble  dated  back 
before  the  time  of  adolescence. 

While  the  disease  is  running  the  course  just  described,  the  pa- 
tient sometimes  suffers  from  attacks  of  vertigo,  and  occasionally 
from  sudden  seizures  resembling  apoplexy,  and  even  epileptiform 
attacks  may  occur.  The  mind  is  usually  not  much  affected.  There 
may  be  some  slight  dulness  of  the  intellect,  some  hebetude,  or  even 
a  slight  amount  of  melancholia.  In  certain  cases  the  patients  are 
subject  to  attacks  of  impulsive  laughing;  that  is  to  say,  without 
any  sufficient  cause  they  suddenly  break  out  in  exaggerated  laugh- 
ter, from  which  they  quickly  recover  themselves.  These  attacks 
may  be  frequently  repeated. 

The  progress  of  the  affection  in  very  variable.  It  sometimes 
goes  steadily  on  without  remissions,  reaching  finally  in  one  or  two 
years  a  chronic  stage,  in  which  the  patient  remains  for  several  years 
without  much  change.  At  other  times  the  progress  of  the  disease 
is  hastened  by  repeated  exacerbations,  accompanied  by  apoplectiform 
or  hemiplegic  attacks.  In  still  other  cases  the  amelioration  con- 
tinues and  remains  permanent,  and  a  practical  cure  takes  place. 
The  various  symptoms  of  the  disease  are  classified  as  cerebral, 
cerebellar,  and  spinal.  The  cerebro-cerebellar  symptoms  consist  in 
modifications  of  speech,  attacks  of  vertigo  and  apoplectiform  sei- 
zures, hemiplegia,  intention  tremor,  mental  changes,  optic  atrophy, 
and  spasmodic  laughing  or  crying.  There  is  sometimes  also  a  cer- 
tain amount  of  deafness  and  perversion  of  taste  and  smell.  Finally, 
lesions  in  the  brain  may  give  rise  to  a  cerebellar  ataxia,  due  to  the 
development  of  the  disease  in  the  cerebellum. 

Under  the  head  of  spinal  symptoms  are  included  the  spasmodic 
paraplegia,  with  some  bladder  and  sexual  weakness,  and  a  slight 
amount  of  sensory  trouble.  There  may  be  also  some  weakness  of 
the  arms.  Occasionally  there  are  noted  some  trophic  troubles,  such 
as  splitting  of  the  nails  and  atrophy  of  the  muscles. 

Aborted  Types  or  "  Formes  Frustes  "  of  Multiple  Scle- 
rosis.— In  some  cases  the  nodules  of  sclerosis  are  so  limited  in 
number  and  so  peculiarly  placed  that  they  give  rise  to  very  atypical 
forms  of  the  disease.  Perhaps  the  most  common  one  is  that  in 
which  the  disease  takes  the  type  of  a  progressive  sjmstic  paraplegia. 
The  patient  suffers  from  weakness  of  the  lower  limbs,  accompanied 
by  stiffness,  cramps,  exaggerated  reflexes,  and  disturbances  in  the 
bladder  and  rectal  functions.     Anaesthesias,  pain,  and  the  girdle 


DISEASES    OF   THE    BRAIN. 


419 


symptom  may  develop.  In  addition  to  this,  however,  a  close  exam- 
ination will  show  some  evidence  of  disease  of  the  optic  nerves  and 
perhaps  disturbances  of  the  eye  muscles.  The  patient  will  have 
nystagmus,  diplopia,  or  other  visual  disorders.  There  will  also  be 
some  attacks  of  vertigo  or  of  epileptoid  convulsions.  The  combi- 
nation of  the  eye  symptoms  with  the  progressive  paraplegia  will 
often  reveal  the  true  character  of  the  disease. 

Pathology. — Grayish  nodules  are  found  distributed  through  the 
brain  and  spinal  cord.    They  vary  in  size  from  a  millimetre  to  two  or 


Fig.  205.  Fig.  206. 

Figs.  205  and  206.  —  Multiple  Cerebro-Spinal  Sclerosis  (Charcot). 

three  centimetres  in  diameter  (one-twenty-fifth  to  one  inch).  They 
are  of  firmer  consistence  than  is  the  surrounding  brain  substance, 
but  are  not  quite  so  hard  as  is  ordinary  connective  tissue.  They 
consist  microscopically  of  fibrous  tissue  which  does  not  seem  to  be 
connected  with  the  walls  of  the  blood-vessels,  as  a  rule.  Very  often 
the  axis  cylinders  of  nerves  can  be  seen  passing  through  the  lesion. 
The  nodules  are  found  most  frequently  in  the  white  matter  of  the 
brain,  more  especially  in  the  pons,  internal  capsule,  and  centrum 
ovale  (Figs.  205,  206).  They  rarely  begin  primarily  in  the  gray 
matter,  but  may  invade  it  secondarily.  The  roots  of  the  peripheral, 
especially  of  the  cranial,  nerves  occasionally  contain  or  are  sur- 
rounded by  these  sclerotic  masses.     In  the  spinal  cord  they  may 


420  DISEASES    OF   THE   NERVOUS    SYSTEM. 

extend  up  and  down  the  gray  and  white  matter  for  a  considerable 
distance,  or  they  may  involve  the  whole  cord  at  a  certain  level,  turn- 
ing it  into  a  fibrous  mass.  The  blood-vessels  surrounding  and  in 
connection  with  these  diseased  areas  show  some  evidences  of  thick- 
ening and  increased  vascularity,  but  no  true  inflammatory  process. 
The  primary  pathological  change  in  multiple  sclerosis  is  as  yet  un- 
known; many  things  point  to  its  starting  originally  from  small  emboli 
or  thrombi  which  lead  to  minute  softenings,  with  a  secondary  repara- 
tive and  sclerotic  process.  The  fact  that  the  disease  follows  infec- 
tive fevers  makes  such  an  origin  of  it  seem  probable.  On  the  other 
hand,  pathological  anatomy  does  not  yet  bear  out  this  view,  and  it 
is  possible  that  the  disease  begins  by  a  primary  degeneration  affect- 
ing first  the  myelin  sheaths  of  the  nerve  fibres,  this  being  followed 


Fig.  207.— Spinal   Sclerosis.    J,  K,  L,  M,  sclerotic  foci;  A,  anterior,  B,  posterior  horn 

(Blocq) 

by  a  neuroglia  and  connective-tissue  proliferation  which  ends  in  the 
formation  of  the  small  islands  of  sclerosis.  An  important  path- 
ological peculiarity  of  the  process  is  that,  while  it  destroys  the  myelin 
sheaths  of  the  nerves,  the  axis  cylinders  remain  intact  for  a  long 
time,  and  consequently  conduction  of  nerve  impulses  takes  place 
imperfectly,  directly  through  the  nodular  masses. 

Course  a  ml  Duration. — The  disease  runs  a  very  irregular  course. 
Its  prodromal  stage  is  long  and  remissions  of  considerable  length 
occur.  The  disease  may  last  from  five  to  fifteen  years,  the  average 
duration  being  five  or  six  years.  Death  sometimes  occurs  from 
involvement  of  the  nerves  of  the  medulla,  but  more  often  from 
weakness  and  exhaustion  or  some  intercurrent  malady. 

Diagnosis. — The  diagnosis  in  typical  cases  is  not  very  difficult; 
but  as,  on  the  other  hand,  typical  cases  are  not  common,  the  dis- 
ease has  always  to  be  studied  with  great  care  before  certainty  can 
be  reached.     The  diagnosis  is  based  upon  the  slow  development  of 


DISEASES   OF   THE    BRAIN.  -±21 

the  disease,  with  attacks  of  vertigo,  weakness,  and  uncertainty  in 
gait;  also  upon  the  paralysis  of  the  extremities  with  intention 
tremor,  ataxia,  rigidity,  and  contractures;  upon  the  disturbances 
of  vision,  nystagmus,  and  the  speech  troubles.  The  presence  of 
headache,  attacks  of  vertigo,  apoplectiform  attacks,  and  the  pecu- 
liar mental  condition  often  furnish  help.  The  age  of  the  patient 
and  the  cause  should  also  be  taken  into  consideration.  The  dis- 
ease must  be  distinguished  from  Friedreich's  ataxia,  spastic  spinal 
paralysis,  locomotor  ataxia,  dementia  paralytica,  bulbar  paralysis, 
paralysis  agitans,  chronic  meningitis,  and  hysteria.  The  points 
already  given  and  those  furnished  under  the  heads  of  these  different 
diseases  must  be  utilized  in  making  these  distinctions.  The  method 
of  exclusion  may  be  used  with  advantage  in  reaching  the  diagnosis 
of  this  protean  malady. 

Prognosis. — The  prognosis,  while  not  favorable  as  regards  the 
ultimate  cure,  is  somewhat  favorable  as  regards  the  remission  and 
improvement,  and  the  disease  on  the  whole  is  not  so  severe  as  is 
locomotor  ataxia  or  the  other  degenerative  disorders. 

Treatment. — In  the  treatment  the  same  measures  recommended 
for  other  chronic  diseases  of  the  nervous  system  must  be  em- 
ployed. Hygienic  measures,  electricity^  and  hydrotherapy  have 
some  therapeutic  value.  Internally  the  use  of  large  doses  of  iodide 
of  potassium,  the  hypodermic  injection  of  arsenic,  the  administra- 
tion of  nitrate  of  silver  and  of  quinine  and  other  tonics  are  advised. 
A  very  regular,  systematic,  and  quiet  mode  of  life,  combined  with 
the  use  of  iodide  of  potassium  and  bichloride  of  mercury,  has  pro- 
duced the  best  results  in  my  experience,  even  in  cases  which  gave 
no  history  of  syphilitic  infection. 

THE   APOPLEXIES. 

Apoplexy  is  a  clinical  term  used  to  indicate  a  condition  charac- 
terized by  sudden  paralysis,  usually  attended  with  loss  of  conscious- 
ness, and  due  to  the  breaking  or  blocking  up  of  a  blood-vessel  in  the 
brain. 

Apoplexy  is  a  general  term.  Particular  forms  are  described  in 
accordance  with  the  cause  of  the  apoplexy.     These  are: 

1.  Intracranial  hemorrhage,  from  rupture  of  a  blood-vessel 
(Hemorrhagic  apoplexy). 

2.  Acute  cerebral  softening,  from  embolism  or  thrombosis  (Em- 
bolic or  thrombotic  apoplexy). 


422  DISEASES    OF   THE    NERVOUS    SYSTEM. 


Apoplexy  from    Intracranial  Hemorrhage   (Cerebral  Hem- 
orrhage, Hemiplegia). 

There  are  four  groups  of  blood-vessels  in  the  brain,  those  of 
the  dura  mater,  those  of  the  pia  mater,  and  those  supplying  the 
basal  ganglia  and  white  matter.  Besides  this,  we  may  consider 
the  pons,  medulla,  and  cerebellum,  which  are  supplied  chiefly 
by  branches  of  the  vertebrals  as  a  separate  group,  subject  to  some- 
what different  mechanical  conditions.  Corresponding  to  this  we 
have: 

1.  Dural  or  pachymeningeal  hemorrhages. 

2.  Fial  or  subarachnoid  hemorrhages. 

3.  Central  hemorrhages. 

4.  Hemorrhages  in  the  medulla,  pons,  and  cerebellum. 

It  is  the  central  hemorrhages  (No.  3),  due  to  rupture  of  the  blood- 
vessels going  to  the  great  basal  ganglia,  internal  capsule,  and  white 
matter,  that  constitute  the  great  majority  of  cerebral  hemorrhages 
seen  by  the  physician.  It  is  this  class  that  I  have  particularly  in 
mind  in  the  following  description. 

Etiology.- — At  the  time  of  birth  and  during  infancy  there  is  a 
slight  tendency  to  intracranial  hemorrhage  OAving  to  the  accidents 
and  injuries  of  labor.  After  this  period  the  liability  is  very  small, 
but  slowly  increases  up  to  the  age  of  forty,  when  predisposition 
specially  begins.  Four-fifths  of  all  cases  occur  after  forty,  and 
the  tendency  to  hemorrhages  increases  in  each  decade  up  to 
eighty,  when  it  diminishes  absolutely  and  relatively.*  Males  are 
slightly  more  predisposed  than  females  (five  to  four).  Rather 
more  cases  occur  in  cold  weather,  at  high  altitudes,  in  the  tem- 
perate zone,  and  among  civilized  races.  Heredity  has  an  un- 
doubted though  not  great  influence  in  predisposing  to  cerebral 
arterial  disease.  Infective  fevers  and  marasmic  states  are  predis- 
posing causes.  Chronic  kidney  disease  is  present  in  one-third 
of  the  cases.  Chronic  alcoholism,  syphilis,  and  gout  are  powerful 
predisposing  causes.  Rheumatism  is  less  important.  Heart  dis- 
ease, fatty  and  atheromatous  arteries,  arteritis,  and  miliary  aneu- 
risms may  be  regarded  as    more  than  simply  predisposing — they 

*  Among  53  cases  collected  by  me  at  Bellevue  Hospital,  the  ages  were  :  10 
to  20,  4 ;  21  to  30,  6  ;  31  to  40,  10 ;  41  to  50,  11  ;  51  to  60,  7  ;  61  to  70,  10 ;  71 
to  80,  5.  The  right  side  was  affected  in  23  cases  ;  the  left  in  25  cases.  The 
location  was  :  Pachymeningeal,  7  ;  pialand  cortical,  8  ;  ventricular,  23  ;  corpus 
striatum  and  vicinity,  7  ;  optic  thalamus,  2  ;  corpora  quadrigemina,  1  ;  pons, 
1 ;  cerebellum,  3. 


DISEASES   OF   THE    BRAIN".  423 

are  determining  causes.  Leucocythsernia,  scurvy,  and  purpura 
are  conditions  which  also  particularly  tend  to  cause  hemorrhage. 
The  so-called  apoplectic  habit  —  short  thick  neck  and  high 
shoulders  and  florid  face  —  has  really  some  importance  in  the 
better  classes.  Congenital  anomalies,  such  as  a  narrow  thoracic 
aorta  or  inherited  deficiency  in  the  strength  of  the  walls  of  the 
blood-vessels,  also  play  a  part.  Any  sudden  physical  exertion, 
such  as  straining  at  stool,  the  excitement  at  coitus  or  of  a  pas- 
sion, eating  a  large  meal  and  drinking  a  great  deal  of  fluid,  es- 
pecially alcohol,  taking  a  cold  bath,  all  may  lead  to  rupture  of  an 
artery. 

The  symptoms  are  the  prodromal,  those  of  the  attack  aud  acute 
stage,  and  those  of  the  chronic  stage. 

Prodromal  symptoms  are  rare  except  in  syphilitic  cases.  When 
present  the  patient  suffers  from  dizziness,  numbness  of  the  hand 
and  foot  on  one  side,  and  a  failure  of  memory  for  words.  He  may 
have  "  full"  feelings  or  even  pain  in  the  head  and  bad  dreams  at 
night.  jSosebleed  and  irregular  heart  action  sometimes  occur.  The 
attack  always  comes  on  suddenly  and  may  be  accompanied  (1)  by 
convulsions  and  coma,  (2)  by  coma  alone,  or  (3)  it  may  come  with- 
out loss  of  consciousness. 

1.  Initial  convulsions  are  rare  and  generally  mean  a  meningeal 
hemorrhage.  When  present  they  are  unilateral  or  partial,  as  a 
rule,  but  may  be  general.  2.  The  common  mode  of  onset  is  with 
coma.  The  patient,  without  warning,  suddenly  becomes  dizzy, 
loses  consciousness,  and  falls.  The  face  is  flushed,  the  pulse  hard 
and  rather  slow,  the  breathing  is  labored  and  stertorous,  the  cheek 
on  one  side  puffs  out  with  each  expiration,  the  eyes  are  partly 
closed,  the  eyeballs  fixed  or  deviated  to  the  paralyzed  side,  the 
pupils  are  contracted  and  rigid,  the  skin  is  bathed  in  sweat,  the 
limbs  are  relaxed,  but  some  evidence  of  hemiplegia  is  present;  the 
urine  may  be  retained  or  it  and  the  fteces  involuntarily  evacuated. 
The  urine  is  usually  of  rather  high  specific  gravity  and  often 
contains  albumin,  even  when  there  is  no  renal  disease.  The  tem- 
perature in  severe  cases  may  fall  below  normal  during  the  first 
twelve  hours,  even  to  96°  F.,  but  this  is  not  the  ride.  It  is  the 
rule,  however,  for  the  temperature  in  a  few  hours  to  be  £°  or  1° 
higher  on  the  paralyzed  than  on  the  sound  side.  If  the  case  is 
rapidly  fatal  coma  continues,  respiration  often  assumes  a  Cheyne- 
Stokes  character,  the  pulse  becomes  faster,  the  temperature 
gradually  rises,  and  usually  reaches  102°  or  103°  F.,  until  just 
before  death,  when  it  may  sink  again.  Swallowing  and  Bpeech 
become  difficult,   hypostatic  pneumonia  sets  in,    and   the    patient 


424  DISEASES    OF   THE    NERVOUS   SYSTEM. 

dies  in  from  two  to  four  days.  In  slower  fatal  cases  the  patient 
regains  consciousness  partially  and  then  enters  a  condition  of 
stupor  or  mild  delirium.  He  is  restless  and  suffers  from  head- 
ache. The  temperature  may  continue  normal  for  a  time,  but  is 
usually  higher  on  the  affected  side.  At  the  end  of  two  or  three 
weeks  it  rises  higher,  pneumonia  develops,  the  patient  becomes 
unconscious,  and  death  ensues.  In  the  favorable  cases,  which 
constitute  the  majority,  coma,  if  present,  gradually  passes  away 
in  from  one  to  six  hours,  leaving  the  patient's  mind  somewhat 
weak  and  confused  and  his  speech  disturbed,  or  more  rarely  the 
intelligence  may  not  be  at  all  disturbed.  During  the  first  few  days 
or  weeks  after  the  attack  the  physician  finds  that  the  prominent 
symptom  is  the  hemiplegia.  This  affects  the  arm  and  leg  most 
and  the  face  least.  Only  the  lower  two  branches  of  the  facial 
nerve  are  involved,  and  the  patient  can.  shut  the  eyes.  The 
tongue,  if  protruded,  turns  to  the  paralyzed  side;  the  uvula  is 
turned  in  various  ways  and  its  position  is  of  no  significance. 
There  is  often  some  evidence  of  cutaneous  anaesthesia  of  the  para- 
lyzed side,  and  less  often  hemianopsia  and  disturbances  of  hearing 
occur.  In  right-sided  hemiplegia  the  patient,  after  recovering 
consciousness,  is  often  unable  to  talk  or  to  understand  what  is 
said.  Examination  shows  that  he  has  a  motor  or  sensory  aphasia 
(ride  Aphasia). 

The  deviation  of  the  eyes  and  head  to  one  side  usually 
disappears  in  a  day  or  two.  Occasionally  there  is  a  temporary 
ptosis.  The  pupils  at  first  are  contracted,  that  on  the  paralyzed 
side  the  more  so;  this  condition  disappears  with  returning  con- 
sciousness. 

The  paralysis  of  the  arm  and  leg  is  flaccid  at  first,  and  the 
limb  falls  heavily  when  lifted ;  the  reflexes  are  lessened  or  abol- 
ished. 

Sometimes,  however,  rigidity  sets  in  at  once.  This  symptom 
occurs  when  blood  has  broken  into  the  ventricles,  and  also  in  some 
meningeal  hemorrhages.  The  skin  reflexes  are  abolished  or  nearly 
so  on  the  affected  side. 

The  usiial  course  of  the  temperature  is  for  it  to  rise  on  the  sec- 
ond and  third  day  to  100°  F.  or  102°  F.,  being  |°  to  1°  higher  on 
the  paralyzed  side.  In  a  few  days  it  gradually  falls,  so  that  by  the 
eighth  to  the  tenth  day  it  is  normal. 

If  the  temperature  continues  to  rise  after  the  fourth  or  fifth  day, 
it  is  a  sign  of  an  extension  or  inflammatory  reaction  of  the  hemor- 
rhage. Hence  the  thermometer  furnishes  a  very  important  criterion 
of  the  seriousness  of  the  case. 


DISEASES    OF   THE    BRAIX. 


425 


The  varying  course  of  the  apoplexy  is  shown  in  the  following 
diagram : 

Health  line. 


Attack 


Improvement. 


3.  Chronic  stage. 
4  to  8  weeks. 


1.  Death. 
2  to  4  days. 


2.  Death. 
2  to  4  weeks. 


The  Chronic  Stage,  Hemiplegia. — At  the  end  of  a  month,  if 
fever  and  symptoms  of  cerebral  irritation  have  subsided,  the  chronic 
stage  may  be  said  to  begin.  The  hemiplegia  has  improved,  the  pa- 
tient can  move  the  leg  and  arm  a  little,  sensory  symptoms  have 
lessened,  the  mind  is  clear,  headache  has  disappeared.  Improve- 
ment continues,  though  more  slowly,  for  several  months  or  even 
one  or  two  years.  During  this  time  the  patient  is  "  a  hemiplegic" 
(Fig.  208). 

The  hemiplegia  affects  the  arm  more  than  the  leg,  and  the  face 
least  of  all.  The  distal  segments  of  the  limbs,  the  feet  and  hands, 
are  affected  more  than  those  near  the  trunk.  The  muscles  that  act 
bilaterally,  such  as  those  of  respiration,  phonation,  and  facial  ex- 
pression, are  but  slightly  involved.  The  paralysis  is  not  strictly  a 
hemiplegia,  for  the  muscles  on  the  sound  side  are  somewhat  weak- 
ened, as  tests  will  show.  In  severe  cases,  especially  in  old  people, 
even  the  visceral  muscles,  especially  those  of  the  bladder,  are 
weakened.  At  the  onset  of  the  attack  there  is  sometimes  a  tem- 
porary "  initial"  rigidity  of  the  muscles  on  the  paralyzed  side, 
or  an  "  early"  rigidity  may  develop  in  one  or  two  days.  There 
always  develops  at  about  the  beginning  of  the  second  week 
a  '"  late"  rigidity.  This,  which  at  first  is  slight,  gradually  in- 
creases, and  finally  contractures  affect  the  paralyzed  limbs.  The 
superficial  reflexes,  which  at  first  were  absent,  reappear;  the  ten- 
don retlrxes  become  much  exaggerated,  and  clonus  can  be  obtained 
in  the  leg  and  arm.  The  sound  side  shares  to  a  small  extent  in 
these  conditions.  The  contractures  affect  the  extensors  of  the  foot 
more  than  the  flexors,  and  bring  the  toe  down  and  the  heel  up. 
The  leg  is  held  nearly  extended,  and  the  limb  in  walking  is  swung 
around,  the  toe  scraping  the  ground.  The  shoulder  is  adducted,  the 
forearm  flexed,  and  the  fingers  are  tightly  shut  into  the  palm  by  the 


426 


DISEASES    OF    THE    NERVOUS   SYSTEM. 


overaction  of  the  flexors  (Fig.  208).       The  facial  muscles  show  a 
slight  contraction  and  drawing  to  the  affected  side.     The  muscles  on 

the  paralyzed  side  do  not  waste. 
In  infantile  hemiplegia,  however, 
the  affected  limbs  grow  less  than 
those  on  the  sound  side. 

The    paralyzed     limbs    may 
be  the  seat  of  peculiar  disorders 
of  movement.     These  consist  of 
Associated  movements. 
Tremor. 
Ataxia. 

Choreic  movements. 
Continuous  or  athetoid  move- 
ments (Fig.  209). 

Spastic      movements      and 
cramps. 

Such  movements,  aside  from 
those  that  are  spastic,  are  rarely 
seen  in  the  hemiplegia  of  adults. 
The  electrical  irritability 
may  be  at  first  slightly  increased 
or  diminished,  but  the  change 
is  small  in  amount  and  never 
reaches  the  degenerative  stage. 

Hemianesthesia,  if  present 
at  first,  disappears  to  a  great 
extent,  leaving  only  residua 
about  the  feet  and  hands. 
Parsesthesise  are  common.  In 
rare  cases  the  patient  suffers 
great  pain  in  the  arm  and  leg. 
This  pain  is  generally  of  a 
burning  character  and  very  obstinate  and  distressing.  Cramping 
pains  in  the  legs  and  arms  are  common  in  the  severer  cases. 

During  the  first  few  weeks  after  the  onset  joint  inflammations 
and  bedsores  may  attack  the  affected  side.  The  temperature  of 
the  hemiplegic  side  is  usually  a  very  little  higher  than  that  of  the 
sound  side. 

Vasomotor  disturbances,  sweating,  skin  eruptions,  and  increased 
growth  of  hair  are  some  of  the  rarer  symptoms. 

The  mental  condition  is  more  or  less  affected.  The  patient 
becomes  irritable,  cries  easily,  and  is  in  general  more  emotional. 


Fig.  208.— A  Case  op  Chronic  Hemiplegia 
with  Contractures  from  Cerebral  Hemor- 
rhage (Curschmanrf  . 


DISEASES    OF    THE    BKAIK.  -£27 

The  memory  is  impaired,  and  the  power  of  concentrating  the  atten- 
tion and  carrying  on  work  is  less.  Sometimes  a  progressive  mental 
deterioration  sets  in  and  epilepsy  or  insanity  develops.  The  mental 
disturbance  is  greater  in  old  people  and  depends  somewhat  on  the 
size  of  the  hemorrhage.  Those  forms  which  produce  serious  aphasia 
especially  limit  and  lessen  mental  activity. 

Meningeal  Apoplexy. — Aside  from  the  apoplexies  due  to  rup- 
ture of  the  central  arteries  and  involvement  of  the  basal  ganglia  just 
described,  there  are  a  minor  number  in  which  the  meningeal  ar- 


Fig.  209.— Showing  Athetoid  Movements  of  Hands  (Curschmann). 

teries,  the  cerebellar,  or  some  branch  of  the  basilar  are  affected; 
hence  we  have  meningeal,  cerebellar,  and  pons  hemorrhages. 

Hemorrhages  from  the  vessels  of  the  dura  mater  are  usually  due 
to  a  rupture  of  the  middle  meningeal  artery  or  vein  or  some  of  its 
branches,  and  this  is  especially  true  in  such  hemorrhages  as  are  the 
result  of  injuries  to  the  head.  The  causes  are  injuries  to  the  head, 
including  obstetrical  injuries,  alcoholism,  and  insanity. 

In  dural  hemorrhages  the  result  of  head  injuries,  the  clot  is 
sometimes  intradural,  lying  in  the  arachnoid  space,  and  sometimes 
epidural,  lying  between  the  bone  and  the  dural  membrane.  The 
extradural  hemorrhages  are  perhaps  a  little  more  common.  In  over 
one-half  of  these  there  is  an  interval  of  consciousness  lasting  from 
a  few  hours  to  two  months,  but  usually  only  a  few  hours,  between 
the  accident  and  the  time  when  distinctive  cerebral  symptoms  de- 
velop. Then  the  patient  gradually  becomes  dull,  somnolent,  and 
finalby  comatose.  In  about  one-half  the  cases  this  interval  of  con- 
sciousness between  the  accident  and  the  development  of  hemiplegia 


428  DISEASES    OF   THE    NERVOUS   SYSTEM. 

is  present.  Along  with,  the  gradual  or  rather  sudden  loss  of  con- 
sciousness there  develops  a  hemiplegia  upon  the  side  opposite  the 
clot.  This  is  usually  not  complete,  though  it  may  become  so.  An- 
aesthesia is  rarely  present.  The  reflexes  are  generally  somewhat 
exaggerated,  and  there  may  be  considerable  rigidity.  Spasmodic 
movements  of  some  kind  occur  in  nearly  half  the  extradural  cases 
and  in  more  than  half  of  the  intradural.  These  spasmodic  move- 
ments may  involve  the  whole  of  the  affected  side,  or  may  simply 
affect  the  eyes  and  the  facial  muscles.  They  consist  of  irregular 
twitchings.  The  pupils  are  usually  somewhat  contracted,  more  so 
upon  the  paralyzed  side.  When  there  is  a  dilated  pupil  on  the  side 
of  the  lesion  and  a  small  pupil  on  the  opposite  side,  it  is  known  as 
the  Butch  iiismt  jfi/jnl,  and  means  a  severe  brain  compression  involv- 
ing the  third  nerve  at  the  base.  The  eyes  are  generally  both  turned 
toward  the  affected  side  and  away  from  the  lesion.  The  pulse  is 
slow  and  full;  the  respiration  is  rarely  stertorous,  though  it  may 
sometimes  be  so,  and  Cheyne-Stokes  respiration  may  be  present. 
In  these  cases  the  clot  is  very  large  and  the  compression  great. 
Aphasia  may  be  present  if  the  clot  is  upon  the  left  side.  The  tem- 
perature may  be  raised  one  or  two  degrees,  or  it  may  be  normal. 
The  progress  of  the  disease  is  usually  steadily  fatal  unless  surgical 
interference  is  undertaken.  The  coma  deepens,  the  respiration  be- 
comes stertorous  and  then  embarrassed,  the  pulse  gets  rapid  and 
weak,  and  the  patient  dies.  With  surgical  interference  (since 
1886),  between  two-thirds  and  three-fourths  of  the  cases  are  saved 
(Scudder  and  Lund) . 

Dural  hemorrhages  occurring  idiopathically  are  due  sometimes 
to  the  rupture  of  a  meningeal  artery,  and  sometimes  to  rupture  of 
the  veins  of  the  pia  mater.  This  idiopathic  hemorrhage  is  rare  in 
ordinary  practice,  but  is  not  specially  so  in  insane  asylums  or  in 
large  city  hospitals.  This  is  because  the  two  great  causes  of  this 
type  of  hemorrhage  are  insanity  and  alcoholism.  General  paresis 
is  the  form  of  insanity  with  which  it  is  oftenest  associated.  In  the 
case  of  alcoholics,  it  is  probable  that  injuries  from  blows  are  an  ex- 
citing factor  in  the  production  of  the  hemorrhage,  these  occurring 
while  the  patient  is  in  a  state  of  intoxication.  The  symptoms  of 
idiopathic  hemorrhage  are  extremely  variable,  owing  to  the  compli- 
cating influences  of  the  insanity  and  alcohol.  The  patient  after 
suffering  from  headaches  or  vertigo  becomes  suddenly  comatose  and 
shows  marked  evidences  of  hemiplegia  and  even  of  anaesthesia. 
Rigidity  of  the  paralyzed  side  is  often  present,  and  sometimes  spas- 
modic movements  are  observed.  On  the  other  hand,  at  times  the 
paralysis  can  hardly  be  observed,  and  the  patient  is  in  a  semicoma- 


DISEASES   OF    THE    BRAIX.  429 

tose  state,  has  a  muttering  delirium,  and  presents  the  general  aspect 
of  a  person  suffering  from  the  oedema  or  "  wet-brain"  of  alcoholics. 
In  dural  hemorrhages  occurring  in  paresis,  the  patient  usually  with- 
out warning  becomes  unconscious,  and  he  often  has  some  convulsive 
symptoms  and  a  hemiplegia  develops.  In  these  cases  there  is  often 
a  rapid  improvement,  and  the  patient  gets  partly  well,  usually  ex- 
periencing other  attacks  later. 

Pial  apolexy  occurs  very  rarely,  and  the  most  frequent  cause 
is  trauma  associated  perhaps  with  syphilis  and  alcoholism.  In 
many  instances  very  slight  localizing  symptoms  occur,  and  no  abso- 
lute diagnosis  can  be  made.  If  the  hemorrhage,  however,  is  in  the 
motor  area  of  the  cortex,  local  spasmodic  movements  and  some  hemi- 
plegia are  observed.  The  most  characteristic  symptoms  are  the 
sudden  incomplete  hemiplegia,  involving,  perhaps,  mainly  an  arm 
or  a  leg,  associated  with  local  spasmodic  movements,  resembling 
Jacksonian  epilepsy. 

Pons  Apoplexy. — This  is  accompanied  by  initial  loss  of  con- 
sciousness and  sometimes  with  spasmodic,  jerking  movements  of  the 
limbs,  more  particularly  of  the  legs.  Some  rigidity  on  both  sides 
of  the  body  may  be  present.  The  facial  or  ocular  nerves  may  be 
involved,  and  speech,  articulation,  and  swallowing  may  be  affected. 
The  pupils  are  often  contracted  almost  to  a  pin  point,  and  the  respi- 
ration is  slow.  The  temperature  almost  always  rises,  and  may  reach 
as  high  as  103°  or  104°  F.  There  may  be  some  disturbance  iu 
sensation  and  some  hemiplegia.  These  hemorrhages  are  usually 
fatal. 

Cerebeixab  ArorLEXY. — Hemorrhage  into  the  cerebellum  oc- 
curs in  one  or  two  per  cent  of  all  fatal  cases.  Its  recognition  is  very 
difficult.  There  is  sometimes  a  preliminary  period  of  severe  head- 
ache, lasting  several  days.  In  other  cases  the  patient  at  once  falls 
into  a  state  of  profound  coma,  with  stertorous  respiration.  Vomit- 
ing sometimes  occurs.  There  may  be  some  hemiplegia,  and  if  so 
this  is  on  the  side  of  the  lesion,  owing  to  this  pressure  on  the  motor 
tract.  Distinct  evidences  of  hemiplegia,  however,  are  not  always 
observed.  The  condition  of  the  pulse  and  arterial  system  is  very 
much  like  that  of  ordinary  apoplexy,  but  the  respiratory  system  is 
usually  more  seriously  affected.  Disturbances  in  the  movements  of 
the  eyes  and  in  swallowing,  and  in  fact  all  those  symptoms  which 
show  a.  pressure  or  irritation  due  to  blood  oozing  into  the  fourth 
ventricle  may  be  present.  Death  is  almost  sure  to  occur,  and  is  in- 
evitable if  the  hemorrhage,  as  is  so  often  the  case,  breaks  through 
and  reaches  the  fourth  ventricle. 

Fathology  and  Morbid  Anatomy. — Spontaneous  intracranial  hem- 


430  DISEASES    OF   THE    NEKVOUS   SYSTEM. 

orrhage  is  always  due  to  the  presence  of  diseased  blood-vessels  in 
the  brain.     This  diseased  condition  consists  of: 

1.  A  degenerative  arteritis  which  results  in  producing  small 
aneurisms.  2.  A  fatty  degeneration  of  the  vessel  walls.  3.  Be- 
sides this,  in  most  cases  the  larger  blood-vessels  are  atheromatous. 

1.  The  arteritis  produces  small  or  miliary  aneurisms  which 
affect  only  the  smaller  arteries,  especially  those  of  the  central 
group.  They  may  be  fusiform  or  sacculated  in  shape;  they  range 
in  size  from  one-fourth  to  one  millimetre  (  yi^  to  -fa  in.)  in  diameter. 
They  are  usually  not  very  numerous,  but  there  may  be  as  many  as 
a  hundred  in  the  brain.  They  are  the  results,  not  of  inflammation, 
but  of  a  degeneration  which  affects  first  an  area  in  the  internal  coat; 
this  causes  local  weakness  and  consequent  dilatation;  secondarily 
there  is  a  periarteritis.  These  aneurisms  occur  almost  exclusively 
during  the  degenerative  period  of  life. 

2.  Fatty  degeneration  of  the  walls  of  the  small  cerebral  arteries 
occurs  in  purpura,  scurvy,  leucocythgemia,  marasmic  conditions, 
and  post-infective  states,  especially  in  early  life,  and  is  the  com- 
mon cause  of  hemorrhage  at  that  time. 

3.  Atheroma  affects  the  larger  vessels  only.  It  is  indirectly  a 
cause  of  hemorrhage  by  lessening  the  elasticity  of  the  vessel  wall. 
Atheroma  is  present  in  from  one-eighth  to  one-fifth  of  all  cases. 
Hypertrophy  of  the  heart  is  a  factor  in  causing  hemorrhage,  and 
such  hypertrophy  exists  in  about  forty  per  cent  of  cases.  Emboli 
lodged  in  the  cerebral  arteries  may  cause  hemorrhage  by  suddenly 
stopping  the  arterial  circulation  and  raising  the  blood  pressure. 
Hemorrhages  are  found  by  far  the  oftenest  (twenty  per  cent)  in  the 
caudate  and  lenticular  nuclei  and  adjacent  parts.  The  lenticular 
and  lenticulo-striate  branches  of  the  middle  cerebral  are  oftenest 
affected ;  next  the  branches  of  the  anterior  cerebral  to  the  caudate  nu- 
cleus and  the  ventriculo-optic  branches  of  the  middle  cerebral.  The 
branches  of  the  posterior  cerebral  break  more  rarely.  The  parts 
affected  in  hemorrhage,  in  order  of  f recpaency,  are  about  as  follows : 

Caudate  and  lenticular  nuclei. 

Meninges  and  cortex. 

Centrum  ovale. 

Optic  thalamus. 

Pons,  cerebellum,  medulla. 

Cortex  hemorrhages  are  generally  small  and  may  be  subarach- 
noid or  may  break  through  into  the  arachnoid  cavity.  Ventricular 
hemorrhages  are  almost  always  secondary  to  a  rupture  into  the 
neighborhood  of  the  basal  ganglia.  Pons  hemorrhages  occur  usu- 
ally in  the  median  line.     Cerebellar  hemorrhages  are  oftenest  due 


DISEASES    OF   THE    BRAIN. 


431 


to  rupture  of  the  superior  cerebellar  artery.  They  visually  cleave 
their  way  externally  and  break  into  the  fourth  ventricle.  Dural 
hemorrhages  are  due  to  rupture  of  the  meningeal  veins  and  arteries 
and  of  the  vessels  in  newly  organized  clots.  They  lie  in  the  arach- 
noid cavity  and  flatten  the  convolutions. 

The  reparative  changes  after  a  hemorrhage  take  the  following 
course:  1st,  Coagulation  of  the  blood,  which  in  a  few  days  begins 


Art  LjS. 


-Art  O.E. 


Fig.  210. — Showing  the  Different  Areas  Commonly  Involved  in  Cerebral  Hemor- 
rhage. Art.  L.S.,  lenticulo-8triate  artery;  Art.  L.  O. ,  lenticular  optic;  Art.  O.  A".,  ex- 
ternal optic. 

to  soften  and  become  absorbed.  2d.  Formation  of  a  fibrinous  wall 
about  the  clot.  This  occurs  from  the  seventh  to  the  ninth  day. 
3d.  Formation  of  a  cyst  with  transparent  fluid  contents,  and  per- 
haps fibrous  trabecular  running  through  it,  twentieth  to  thirtieth 
day.  4th.  Contraction  of  the  cyst  wall,  which  begins  by  the  fortieth 
day.  5th.  Secondary  degenerations  begin  from  the  tenth  to  the 
fourteenth  day. 

Physiology. — The  blood  pressure  of  the  cerebral  arteries  is  equal 
to  about  156  mm.  of  mercury.  The  resistance  or  support  furnished 
by  the  surrounding  tissue  is  equal  to  about  10  mm.  of  mercury. 


432  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Hence  there  is  a  special  liability  to  rupture  of  intracranial  vessels. 
The  middle  cerebrals  are  most  often  affected,  because  they  are  in 
the  most  direct  line  from  the  heart  and  are  nearest  to  that  organ. 
The  pressure  lessens  as  the  arteries  subdivide  and  get  farther  away 
from  the  heart  (Mendel). 

The  diagnosis  of  hemorrhagic  apoplexy  must  be  made  from  alco- 
holic coma,  uraemic  coma,  opium  coma,  epilepsy  and  hysteria;  acute 
softening  from  embolism  and  thrombosis. 

From  alcoholic  coma  the  diagnosis  is  made  by  the  odor  of  the 
breath,  the  incomplete  coma,  the  equal  pupils,  the  absence  of  low 
or  unequal  temperature. 

From  ursemic  coma  by  the  absence  of  albumin  and  casts  in  the 
urine,  though  their  presence  does  not  surely  indicate  uraemia;  by 
the  unequal  pupils,  the  temperature,  the  absence  of  hemiplegia  and 
of  the  physiognomy  peculiar  to  cases  of  chronic  Bright' s  disease. 

From  opium  poisoning  by  the  history,  the  stomach  contents,  the 
presence  of  equal  and  contracted  pupils,  the  slow  respirations,  the 
temperature,  and  the  absence  of  paralysis. 

From  epilepsy  by  the  history  of  the  onset  with  epileptic  cry,  the 
dilated  and  equal  pupils,  the  biting  of  the  tongue,  the  absence  of 
hemiplegia,  the  rather  rapid  return  of  consciousness. 

Hysterical  attacks  present  little  semblance  to  that  of  apoplexy; 
hysterical  hemiplegia  is  characterized  by  its  flaccidity,  by  its  not 
involving  the  face,  and  by  the  presence  of  the  anaesthesias  and  other 
hysterical  stigmata. 

In  embolic  softening  the  earlier  age  of  the  patient,  the  presence 
of  decided  valvular  heart  disease,  the  parturient  condition,  the 
slighter  degree  and  shorter  duration  of  coma,  the  absence  of  seri- 
ous disturbance  of  temperature,  the  onset  first  of  paralysis  and  then 
of  convulsive  movements  and  coma — all  lead  to  a  presumption  in 
favor  of  embolism. 

The  presence,  on  the  other  hand,  of  a  congested  face,  tense 
pulse,  and  throbbing  carotids  favors  the  existence  of  a  hemorrhage. 

From  thrombotic  softening  diagnosis  is  more  difficult.  The  oc- 
currence of  prodromata,  consisting  of  slight  seizures  quickly  recov- 
ered from,  the  slighter  degree  of  coma,  the  advanced  age,  hard 
atheromatous  arteries,  evidence  of  anaemia  and  asthenia,  Aveak  or 
fatty  heart,  the  absence  of  stertorous  respiration,  flushed  face,  and 
unequal  temperature  not  much  lowered  or  raised,  the  slight  pupil- 
lary disturbance,  and  absence  of  convulsions  point  to  thrombotic 
softening.  Evidence  of  a  lesion  in  the  pons  or  cerebellum  suggests 
hemorrhage,  while  evidence  of  lesion  in  the  medulla  points  almost 
surely  to  softening. 


DISEASES   OF   THE    BRA IX.  433 

The  chances  in  any  case  between  the  ages  of  thirty  and  fifty,  if 
there  is  no  heart  disease,  are  six  to  one  in  favor  of  hemorrhage. 

Prognosis. — The  majority  of  cases  get  over  the  first  attack. 
They  are  very  liable  to  have  another  within  one  to  five  years.  The 
minority  recover  from  this.  Few  survive  a  third  attack.  The 
prognosis  of  the  attack  itself  depends  on  the  severity  of  the  coma 
and  paralysis,  the  disturbance  of  temperature  and  of  respiration, 
the  evidence  of  rupture  into  the  ventricles,  the  development  of  de- 
cubitus, the  continuance  of  loss  of  control  over  the  bowels  and 
bladder. 

If  profound  coma  continues  four  days  there  is  little  hope;  if 
fever  develops  and  continues  steadily,  or  if  there  is  initial  sub- 
normal temperature,  the  prognosis  is  grave. 

If  the  patient  passes  the  first  week  with  little  or  no  fever  and 
consciousness  has  returned,  the  prognosis  is  good. 

The  presence  of  renal  disease  and  of  alcoholism  is  bad.  Devel- 
opment of  slight  delirium  which  continues  is  unfavorable. 

Cerebellar  and  pons  hemorrhages  are  very  fatal,  meningeal 
slightly  less  so. 

The  prognosis  of  the  chronic  stage  has  been  given  under  symp- 
toms. 

Improvement  continues  rather  rapidly  for  three  months,  then 
very  slowly.  Improvement  may  continue  for  one  or  two  years. 
Complete  recovery  is  very  rare.  The  great  danger  after  middle  age 
is  recurrence  of  the  attack. 

Treatment  of  tlte  Attach. — The  patient  should  be  laid  in  a  hori- 
zontal position  and  kept  quiet.  Ice  should  be  applied  to  the  head 
and  hot  bottles  at  the  feet.  The  feet  and  legs  should  be  swathed 
in  cloths  wrung  out  in  hot  water  containing  mustard,  a  capful  to 
a  pail  of  water.  A  laxative  should  be  given,  either  one  or  two 
drops  of  croton  oil  or  a  quarter  of  a  grain  of  elaterium.  If  there 
is  evidence  of  intense  cerebral  congestion,  the  pulse  being  very  full 
ami  hard  and  the  heart  beating  Btrongly,  bleeding  eight  to  ten 
ounces  is  justifiable.  Ordinarily  it  is  better  to  give  a  drop  of  tinc- 
ture of  aconite  every  twenty  minutes  for  two  or  three  hours.  Pres- 
sure on  the  carotid  of  the  sound  side  and  even  ligature  of  it  have 
been  recommended,  but  there  is  no  experience  yet  to  justify  either. 
Administration  of  bromide  of  sodium  and  enemata  of  ergoi  have 
been  advised,  but  are  of  doubtful  value.  Alter  the  first  twelve 
hours,  treatment  must  be  symptomatic.  Should  delirium  and  other 
evidence  of  mental  irritation  appear,  large  blisters  must  be  applied 
at  the  back  of  the  neck  and  an  elaterium  purge  given  if  the  patient 
is  not  too  weak.  The  use  of  iodide  of  potassium  or  mercury  is  noi 
28 


434  DISEASES   OF   THE    NERVOUS   SYSTEM. 

indicated  unless  the  case  is  distinctly  syphilitic.  The  passage  of  a 
galvanic  current  through  the  brain  cannot  possibly  do  any  good. 
Great  care  should  now  be  taken  that  the  patient  does  not  develop 
pneumonia.  The  mouth  and  pharynx  should  be  cleansed  antisepti- 
cally,  and  the  patient  should  not  be  allowed  to  remain  in  one  posi- 
tion. If  there  is  sufficient  evidence  of  a  meningeal  or  cortical  clot, 
trephining  should  be  seriously  considered. 

At  the  end  of  three  or  four  weeks  the  faradic  battery  may  be 
used  carefully  on  the  affected  limbs.  A  seance  of  fifteen  minutes 
daily  for  four  to  six  weeks  should  be  given,  then  treatment  should 
be  suspended  for  a  fortnight,  to  be  begun  again  and  kept  up  syste- 
matically for  a  year  if  need  be.  Massage  may  be  alternated  with 
the  electricity.  When  contractures  develop  the  stabile  galvanic 
current  may  be  tried,  though  it  does  little  good.  Static  sparks, 
however,  are  helpful;  lukewarm  baths  should  be  tried  and  meas- 
ures used  to  produce  hyperextension  of  the  affected  parts. 

Internally  during  this  time  the  patient  is  to  be  given  courses  of 
iodide  of  potassium,  tonics,  and  laxatives  if  needed.  The  patient 
should  be  made  to  live  a  quiet  life,  preferably  in  a  warm,  equable 
climate.  The  kidneys  should  be  kept  active  and  arterial  tension 
low.  For  these  purposes  nitroglycerin  should  be  given  and  at  times 
small  doses  of  chloral,  and  the  diet  should  be  simple  and  rather 
non-nitrogenous.  Strychnine  in  very  small  doses  (gr.  Tfa)  sometimes 
helps  the  contractures ;  so  also  do  the  bromides  and  physostigma. 

Acute  Softening  of  the  Brain  (Embolism,  Thrombosis). 

Acute  softening  is  a  condition  caused  by  the  plugging  of  a  blood- 
vessel with  an  embolus  or  thrombus,  and  is  characterized  by  a  sud- 
den apoplectic  seizure;  the  symptoms  eventually  running  a  course 
like  those  of  cerebral  hemorrhage. 

Etiology. — Embolism  occurs  rather  more  often  in  women,  throm- 
bosis in  men.  Embolism  is  rare  in  children ;  it  occurs  oftenest  be- 
tween the  ages  of  twenty  and  fifty,  thrombosis  betweeen  the  ages 
of  fifty  and  seventy.  The  most  important  predisposing  factors  in 
embolism  are  acute  or  recurrent  endocarditis,  infe3tious  fevers,  pro- 
found anaemia,  pregnancy,  and  blood  dyscrasias;  in  thrombosis, 
syphilitic,  lead,  or  gouty  arteritis,  fatty  heart,  and  blood  dyscrasias. 
The  same  causes  which  lead  to  the  arterial  disease  which  produces 
cerebral  hemorrhage  also  predispose  to  thrombosis,  though  in  the 
latter  condition  atheroma  plays  the  important  part. 

Symptoms. — In  embolism  there  are  rarely  any  premonitory 
symptoms ;  the  onset  is  sudden ;  it  may  begin  with  some  convulsive 
twitchings,  then  follow  hemiplegia  and  temporary  loss  of  conscious- 


DISEASES   OF   THE   BRAIN.  435 

ness.  Coma,  however,  is  rarer  than  in  hemorrhage,  and  if  present 
is  usually  shorter.  There  is  rarely  vomiting,  nor  do  we  find  the 
hard,  pulsating  arteries,  flushed  face,  and  severely  stertorous  breath- 
ing. The  initial  temperature  changes  are  slight,  but  in  a  few  days 
fever  may  develop. 

In  thrombosis  premonitory  symptoms  are  frequent.  In  syphi- 
litic cases  there  are  headaches  and  cranial-nerve  palsies.  In  other 
cases  vertigo,  temporary  aphasia,  transient  hemiplegia,  numbness 
of  the  hand  and  foot,  and  drowsiness  may  be  present.  The  onset 
is  more  gradual;  the  hemiplegia  slowly  develops,  taking  several 
hours,  perhaps,  for  its  completion ;  meanwhile  the  patient  gradually 
becomes  comatose.  The  attack  sometimes  is  rather  sudden,  with 
no  loss  of  consciousness,  and  it  may  occur  in  sleep.  The  tempera- 
tare  often  has  a  slight  initial  fall,  followed  by  a  rise,  just  as  in 
nemorrnage.  In  both  embolism  and  thrombosis  the  hemiplegia 
tends  to  improve  very  much  in  a  few  days  or  weeks  unless  the  ves- 
sel obliterated  is  a  large  one.  Embolism  is  rather  more  apt  to  affect 
the  left  side  of  the  brain,  though  the  difference  is  not  great.  The 
middle  cerebrals  are  most  frequently  affected  (seventeen  out  of 
twenty-seven  cases).  Softenings  affect  the  vertebrals,  basilar,  and 
posterior  cerebral  arteries  more  often  relatively  than  do  hemor- 
rhages ;  then  the  initial  symptoms  may  not  present  the  character 
of  hemiplegia,  but  of  a  bulbar  paralysis.  Acute  softening  may  kill 
within  twenty-four  hours,  but,  as  a  rule,  the  patient  survives  the 
onset,  and  if  he  dies  it  is  not  for  several  weeks.  After  the  acute 
stage  is  over  the  patient  passes  into  the  chronic  stage,  which  re- 
sembles in  nearly  all  respects  that  of  hemorrhage.  After  an  acute 
softening,  however,  it  is  believed  that  there  are  more  spastic  symp- 
toms and  a  greater  tendency  to  mobile  spasm.  In  embolism,  owing 
to  the  youth  and  freedom  from  arterial  disease,  the  mind  is  less 
affected;  while  in  thrombosis  the  contrary  is  the  case. 

Pathology. — The  embolic  plug  cuts  off  the  blood  supply  from  a 
certain  area  of  brain  tissue.  In  twenty-four  hours  this  begins  to 
soften.  If  the  area  is  in  the  cortex  it  becomes  red  (red  softening); 
if  in  the  white  and  less  vascular  part,  it  is  usually  white  with  a  few 
red  punctate  spots.  The  red  softening  gradually  becomes  yellow 
(yellow  softening).  The  dead  tissue  softens  and  is  absorbed,  leav- 
ing a  cicatrix  or  cyst.  If  the  embolus  contains  infective  microbes 
there  may  be  a  local  encephalitis  and  abscess. 

In  thrombosis  there  are  usually  evidences  of  extensive  athe- 
roma or  syphilitic  arteritis.  Tn  those  instances  in  which  the  throm- 
bosis is  caused  by  the  blood  state  and  a  weak  heart,  little  arterial 
change  occurs.     Atheroma  affects  chiefly  the  internal  carotids  and 


4:}P>  DISEASES    OF   THE    NERVOUS   SYSTEM. 

the  large  arteries  at  the  base,  viz.,  the  middle,  anterior,  and  poste- 
rior cerebrals  and  the  basilar  and  vertebrals.  Thrombosis  with 
apoplexy  occurs  oftenest  in  the  corpora  striata  and  optic  thalamus, 
next  in  the  pons  and  medulla.  Embolism  almost  always  affects 
the  great  basal  ganglia  or  some  cortical  branch  of  the  anterior  and 
middle  cerebrals.  The  secondary  changes  after  thrombosis  resemble 
those  after  embolism ;  a  thrombus,  however,  may  lead  to  supple- 
mentary embolism  through  breaking  off  of  a  clot,  and  both  condi- 
tions may  cause  a  complicating  cerebral  hemorrhage. 

The  Diagnosis.— The  important  points  have  been  gone  over 
under  the  head  of  hemorrhage.     They  may  be  tabulated  in  part  here. 

Hemoeehage. 

Age,  thirty  to  fifty. 

Hereditary  history  of  arterial  disease. 

Sudden  onset,  with  coma  and  paralysis  occurring  together,  the 

la  deepening. 

Initial  and  early  rigidity. 

Very  unequal  pupils. 

Stertorous  breathing  and  hard,  rather  slow  pulse. 

Peculiar  alternating  conjugate  deviation. 

Early  rigidity. 

Peculiar  disturbances  of  temperature,  as  described. 

Acute  Softening. 

Earlier  or  later  age. 

History  of  syphilis. 

Premonitory  symptoms  and  more  gradual  onset  (in  thrombosis), 
more  transitory  coma  or  absence  of  coma. 

Initial  convulsive  movements. 

Presence  of  weak  heart  (in  thrombosis)  or  endocarditis  (in 
embolism) . 

Slight  hemiplegia  with  anaesthesia. 

The  puerperal  state  (embolism). 

Embolism  is  distinguished  by  the  age,  the  presence  of  endo- 
carditis, of  the  puerperium  or  infective  fevers,  and  by  the  sudden 
onset,  with  perhaps  some  convulsive  movements.  Thrombosis  oc- 
curs oftener  in  the  aged,  and  there  are  prodromata — a  slower  onset 
and  evidence  of  arterial  disease  and  a  weak  heart. 

The  prognosis  as  regards  the  attack  is  somewhat  better  than  in 
hemorhage,  as  a  rule.  In  embolism  it  is  good  as  regards  recurrence; 
in  thrombosis,  bad.  The  mental  condition  is  better  in  embolism; 
usually  worse  in  thrombosis.     The  recovery  from  attacks  is  more 


DISEASES    OE   THE    BRAIN.  437 

complete  in  acute  softening.     After  the  chronic  stage  is  reached, 
however,  the  prognosis  is  about  the  same  in  all  forms. 

The  treatment  of  the  attacks  consists  essentially  in  rest  ami  such 
attention  to  the  bowels,  kidney s,  and  heart  as  may  be  indicated. 
In  thrombosis  it  may  be  important  to  give  heart  stimulants  and  ar- 
terial depressants,  and  for  this  purpose  I  advise  the  use  of  alcohol, 
digitalis,  or  strophanthus  with' nitroglycerin.  Indide  of  potassium 
and  mercury  ought  to  be  given  if  there  is  the  slightest  suspicion  of 
syphilis.  Later  it  is  well  to  give  courses  of  the  iodides  and  mer- 
cury and  of  strophanthus,  nitroglycerin,  strychnine,  and  such  tonics 
as  may  be  indicated.  The  symptomatic  treatment  of  the  chronic 
stage  is  the  same  as  in  hemorrhage. 

I  ikebral   Palsies  of   Children — Infantile    Hemiplegia    and 
Diplegia,  Little's  Disease. 

The  brain  palsies  of  early  life  show  themselves  in  the  form  of 
(1 )  hemiplegias ;  (2)  diplegias  or  double  hemiplegias,  in  which  both 
sides  of  the  body  are  involved;  and  (3)  paraplegias,  in  which  the 
lower  limbs  are  chiefly  or  entirely  involved.  In  these  palsies,  as 
in  the  same  troubles  of  adult  life,  the  loss  of  motor  power  is  always 
accompanied  by  a  rigidity  and  by  some  contractures  and  exag- 
geration of  reflexes,  in  this  respect  distinguishing  these  paralyses 
from  those  of  spinal  origin.  The  seat  of  lesion  in  these  cases  is  in 
the  hemispheres  of  the  brain,  and  it  is  the  central  motor  neurons 
which  are  involved;  that  is  to  say,  that  part  of  the  direct  motor  tract 
winch  extends  from  the  brain  cortex  down  to  the  spinal  cord  as  far 
as  the  anterior  horns.  The  brain  palsies  of  children  are  therefore 
disorders  of  the  cortico-spinal  neurons,  while  the  spinal  palsies  of 
children  are  disorders  of  the  neuro-spinal  neurons. 

Etiology.— The  disease  occurs  rather  oftener  in  males  than  in 
females,  though  the  difference  is  alight.  The  vast  majority  occur 
in  the  first  three  years  of  life;  about  one-third  of  them  are  congeni- 
tal. Injuries  to  the  mother  during  the  time  of  pregnancy,  possibly 
diseases  and  emotional  disturbances  at  this  time,  are  factors  in  pro- 
ducing the  congenital  cases.  Those  cases  that  occur  at  the  time  of 
birth  are  due  to  tedious  labor,  the  llSfi  of  forceps,  and  other  injuries 
at  the  time  of  parturition.  After  birth,  the  causes  are  those  which 
lead  to  the  production  of  intracranial  hemorrhages,  embolism,  and 
thrombosis;  these  being  injuries  and  the  infectious  fevers.  Of  the 
latter,  pneumonia,  whooping-COUgh,  measles,  and  scarlet  fever  are 
the  most  prominent.  Syphilis  is  a  rare  cause;  cerehro-s]iiual  men- 
ingitis and  epileptic  convulsions  are  also  occasional  causes. 

Symptomatology.  —  The  disorder  in  about  one-fourth  of  the  ,■ 


438  DISEASES    OF   THE    NEKVOUS    SYSTEM. 

begins  with  a  convulsion,  which  may  be  unilateral,  but  is  usually 
general  in  character,  and  may  last  for  several  hours.  At  the  same 
time  a  febrile  process  develops,  and  this  continues  for  several  days. 
When  these  acute  symptoms  have  subsided,  or  before  this,  it  is 
noticed  that  the  child  is  paralyzed  upon  one  side,  the  paralysis  in- 
volving the  arm,  leg,  and  face,  as  in  adult  hemiplegia,  or  perhaps  in- 
volving both  sides.  This  paralysis  undergoes  gradual  improvement, 
the  face  recovering  earliest  and  most,  the  leg  next,  and  the  arm  least. 
As  the  child  develops  it  is  found  that  the  paralyzed  side  fails  to 
grow  as  fast  as  the  other,  and  there  may  be  from  one-half  to  one  inch 
or  two  inches  of  shortening  in  the  arm  or  leg.  The  circumference  of 
the  limbs  is  less,  the  surface  somewhat  colder,  and  some  vasomotor 
disturbance  may  be  present.  With  the  progress  of  the  case  a  rigid- 
ity of  the  affected  limbs  develops;  the  heel  becomes  drawn  up,  so 
that  there  is  talipes  equino-varus  or  equino-valgus.  The  flexors  of 
the  forearm  and  of  the  wrist  and  fingers  contract,  as  do  also  the  ad- 
ductors of  the  thighs.  In  general  it  will  be  found  that  there  is  a 
contraction  of  the  flexors  and  adductors  of  the  affected  limbs.  With 
this  rigidity  and  the  contractures  there  are  exaggeration  of  reflexes 
and  clonus  in  most  cases.  In  the  disordered  limbs  the  peculiar  mo- 
bile spasms  develop.  These  consist  of  athetoid,  choreic,  and  ataxic 
movements,  also  sometimes  tremors  and  associated  movements.  The 
choreic  and  athetoid  movements  are  the  most  common  (Fig.  209). 

Along  with  the  appearance  of  these  symptoms  it  is  noticed  that 
there  are  disturbances  in  the  mental  condition  of  the  child.  It 
is  usually  backward  in  development,  this  backwardness  ranging 
from  simply  feeble-mindedness  to  complete  idiocy.  Taking  all 
cases,  there  is  about  an  equal  division  between  feeble-mindedness, 
imbecility,  and  idiocy  (Sachs).  Perhaps  a  little  over  one-fourth  of 
the  subjects  have  a  fair  intelligence.  There  is  usually  slowness  in 
learning  to  talk,  and  in  a  small  proportion  of  cases  there  is  a  de- 
cided aphasia.  Such  condition  is  rather  more  frequent  with  right 
hemiplegia  than  with  left  hemiplegia,  though  the  rule  is  not  an  ab- 
solute one.  In  connection  with  the  mental  defect  there  may  develop 
many  of  the  peculiar  moral  traits  associated  with  idiocy  and  low  de- 
grees of  intelligence.  Epilepsy  very  frequently  complicates  the  dis- 
ease; nearly  one-half  of  the  subjects  suffer  from  this  trouble.  This 
epilepsy  is  in  most  cases  general  in  character;  in  a  few  cases  it 
takes  the  Jacksonian  type,  in  a  small  number  petit  vial  alone  is 
noted.  Examination  of  this  class  of  sufferers  reveals,  aside  from 
the  paralysis  described,  various  evidences  of  defective  development. 
These  are  known  as  stigmata  of  degeneration ;  though  they  cannot 
be  classed  strictly  among  such,  since  they  are  acquired  stigmata  in 


DISEASES   OF   THE   BKALN".  439 

most  cases,  rather  than  marks  which  are  the  result  of  primary  de- 
ficiency in  development.  These  stigmata  consist  of  a  microcephalic 
or  a  macrocephalic  skull,  cranial  and  facial  asymmetry,  progna- 
thism, imperfectly  developed  teeth,  and  a  high  palatal  arch.  It  has 
been  found  that,  as  a  rule,  in  cases  of  cerebral  hemiplegias  of  child- 
hood the  patient  eventually  has  a  slight  flattening  of  the  skull  on 
the  side  of  the  lesion  (Fisher  and  Peterson).  Finally,  in  a  few 
cases  there  may  be  found  defects  in  the  special  senses,  such  as  im- 
perfect hearing,  deafness,  deaf -mutism,  and  defects  in  vision  such 
as  hemianopsia,  and  perhaps  imperfections  in  smell  and  taste. 
Anaesthesia  is  never  observed. 

The  symptoms  in  the  cerebral  palsies  of  children,  having  passed 
the  acute  stage  and  having  become  somewhat  ameliorated,  enter  into 
a  chronic  stage.  This  chronic  stage  begins  within  a  few  months  after 
birth  or  after  the  onset  of  the  disease.  !N~o  great  change  occurs  in 
the  paralyses  as  the  child  grows  older  until  he  reaches  the  time  of 
puberty,  though  there  is  a  slight  improvement  in  most  cases.  After 
the  time  of  puberty,  if  the  mental  condition  of  the  child  is  good,  the 
physical  symptoms  are  apt  to  improve  considerably. 

Morbid  Anatomy. — The  primary  changes  that  lead  to  the  cere- 
bral palsies  of  children  are:  1st,  simple  agenesis  or  lack  of  brain 
development,  producing  localized  atroplry  of  the  cerebrum  and  the 
condition  known  as  -porencephalus  (true  porencephalies  is  a  condi- 
tion in  which,  owing  to  a  congenital  defect  in  nutrition,  a  cavity  or 
depression  exists  in  the  cerebral  hemispheres,  this  cavity  reaching 
generally  into  the  lateral  ventricle;  true  porencephalus  is  found 
in  about  one-fourth  of  the  cases,  though  no  definite  statistics  can 
be  given,  owing  to  the  different  interpretations  given  to  this  term); 
2d,  hemorrhage,  which  is  probably  the  most  frequent  of  the  single 
causes;  3d,  embolism;  4th,  thrombosis;  5th,  meningo-encephalitis 
and  perhaps  polio-encephalitis;  6th,  a  diffuse  cortical  sclerosis. 
Many  other  terms  are  used  to  describe  the  pathological  conditions. 
found  at  the  Insis  of  the  brain  palsies  of  children,  but  the  prin- 
cipal causes  of  all  are  undoubtedly,  as  has  been  described,  hemor- 
rhages, embolism  and  thrombosis,  and  a  defective  development  or 
agenesis.  It  is  probable  that  in  the  hemiplegics  the.  original  lesion 
is  generally  a  central  hemorrhage,  less  often  a  meningeal  hemor- 
rhage. After  this,  probably  the  most  frequent  condition  is  a  por- 
encephalus from  some  intra-uterine  accident,  which  may  have  been 
defective  nutrition  causing  anaemia  and  softening,  or  hemorrhage,  or 
thrombosis.  Polio-encephalitis  or  inflammation  of  the  cortex  of  the 
brain  of  the  kind  similar  to  polio-myelitis  is  alleged  to  be  a  cause  in 
some  cases  by  Strumpell,  but  this  has  not  yet  been  proven.     In 


440 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


double  hemiplegias  or  diplegias  of  children  the  cause  is  in  the  vast 
majority  of  cases  a  meningeal  hemorrhage  due  to  some  injury  or 
disturbance  at  the  time  of  labor.  In  other  cases  of  diplegia  the  le- 
sion is  a  double  porencephalus,  which  may  be  either  the  result  of  an 
int va-uterine  hemorrhage  or  simply  a  defective  development.  In  the 
paraplegias  the  lesion  is  probably  very  much  the  same  as  in  the  di- 
plegias, that  is  to  say.  either  a  meningeal  hemorrhage  or  a  brain 
agenesis.     Occasionally  a  diffuse  sclerosis  has  been  found  in  these 


Fig.  211.— Atrophied  Brain  -with  Sclerosis  and  a  Cyst,  from  a  Case  ok  Infantum 
Cerebral  Hemiplegia. 

cases.  Not  infrequently,  as  the  result  of  hemorrhages,  there  develop 
cysts  which  fill  up  the  atrophied  areas  of  the  brain  (Fig.  211).  It 
is  difficult  to  present  accurately  and  definitely  the  relations  between 
the  pathological  change  and  the  clinical  result,  but  it  may  be  shown 
with  some  detrree  of  correctness  in  the  following  table. 


Original  Lesions. 

Later  Pathological  Condition. 

Clinical  Result. 

Hemorrhage. 

Einliolisin. 

Thrombosis. 

Agenesis. 

(  Atrophy. 

|  L< ili.ir-  sclerosis. 
■{  Cysts. 

Porencephaly. 
]  Microcephaly. 

f  Hemiplegia. 
j  Diplegia. 
J  Paraplegia. 
]  Sensory  defects. 
|  Mental  defects. 
[Epilepsy,  etc. 

DISEASES    OF   THE    BRAIN. 


441 


Diplegia  or  Btrth  Palsies. — That  form  of  the  brain  palsies 
of  childhood  characterized  by  double  hemiplegias  or  diplegias  has 
certain  special  characters  which  lead  to  its  being  often  classed  apart. 
These  diplegias  in  almost  all  cases  are  congenital  and  are  due  either 
to  injuries  at  the  time  of  birth  or  to  some  disorders  of  intra-uterine 
life.     There  may  be  convulsions  or  a  prolonged  state  of  asphyxia  at 


Fig.  212.  Fig    313. 

Figs.  21:.'  ami  213.— Cebebral  Diplegia  with  Contractures  and  Talipes. 
ing;  Fig.  210,  suspended  by  arms 


Fit,'  20!),  staud- 


the  time  of  birth.  After  recovery  from  this  no  special  trouble  is 
noticed  with  the  child  by  the  mother  for  some  weeks  or  months, 
when  it  will  be  found  that  it  does  not  use  its  arms  or  legs.  (  Hikes 
convulsions  develop,  and  eventually  the  features  of  a  double  hemi- 
plegia with  mental  impairment  and  epilepsy  are  observed  (Figs. 
212,  _M.">).  In  these  cases  the  mental  defect  is  much  more  decided 
than  m  the  hemiplegias;  indeed,  few  of  these  eases  ever  show  any 
good  amount  of  intelligence.  Epilepsy  is  extremely  common.  The 
anatomical  lesion  in  the  cases  is,  as  already  stated,  either  a  menin- 
geal hemorrhage  which  has  pressed  upon  ami   injured  the  cortical 


442  DISEASES    OF   THE    NERVOUS   SYSTEM. 

motor  areas  in  each  hemisphere,  or  it  is  a  congenital  porencephalic 
defect. 

Spastic  Cerebral  Paraplegia,  Little's  Disease. — In  a  few 
cases  the  brain  lesion  is  such  that  there  results  little  disturbance 
to  the  arms  or  face;  the  paralysis  is  largely  confined  to  the  lower 
extremities.  The  mental  condition  is  often  very  good,  and  there  is 
no  epilepsy.  As  the  child  gets  older  great  improvement  in  the  use 
of  the  limbs  may  occur.  There  are,  however,  rigidity  and  contrac- 
tures of  the  limbs,  exaggerated  reflexes  and  spasms  of  the  flexors 
and  the  adductors,  so  that  the  child's  legs  cross  each  other  and  in- 
terfere in  its  feeble  attempts  at  walking.  The  disease  is  thought  to 
be  due  to  a  developmental  defect  in  the  motor  tracts,  and  it  is  pos- 
sible that  in  some  cases  only  the  spinal  cord  is  affected. 

Diagnosis. — The  clinical  diagnosis  of  cerebral  palsies  is  to  be 
made  from  the  spinal  palsies.  The  latter  are  distinguished  by  the 
fact  that  in  the  paralyses  of  spinal  origin  there  is  no  rigidity  or  ex- 
aggeration of  reflexes,  and  there  are  electrical  degenerative  reactions 
of  the  muscles  and  decided  wasting  of  the  limbs  with  shortening. 
The  mode  of  onset  in  cerebral  palsies  and  their  distribution  in  the 
form  of  hemiplegias  in  which  the  face  is  involved  also  indicate  the 
seat  of  the  lesion.  The  pathological  diagnosis  is  by  no  means  an 
easy  one.  Cerebral  palsies  occurring  at  the  time  of  birth  and  ac- 
companied at  that  time  by  general  convulsions  or  asphyxia  may 
be  considered  to  be  due  to  meningeal  hemorrhage,  especially  if  the 
delivery  of  the  child  has  been  brought  about  by  the  use  of  forceps 
or  if  the  labor  has  been  long  and  tedious.  Diplegias  and  paraple- 
gias which  are  congenital  are  probably  due  to  true  porencephalus, 
provided  there  was  no  difficulty  at  the  time  of  labor  and  there  were 
no  convulsions  or  other  serious  phenomena  after  it.  Cerebral  pal- 
sies occurring  after  birth  in  the  first,  second,  or  third  year  of  life 
are  apt  to  be  due  to  hemorrhage,  and  less  often  to  embolism  or 
thrombosis.  Hemiplegias  developing  after  infectious  fevers  are 
likely  to  be  due  to  hemorrhage.  In  diagnosticating  the  pathological 
lesion  in  such  cases  it  must  always  be  remembered  that  hemor- 
rhage is  much  more  frequent  than  embolism,  and  that  thrombosis 
as  a  factor  has  not  yet  been  very  clearly  established. 

Course  and  Prognosis. — In  all  types  of  the  disease  the  course  is 
chronic  and  perfect  cure  is  hardly  possible,  although  in  the  slighter 
forms  of  hemiplegia  nearly  all  traces  of  the  paralysis  may  be  ab- 
sent. In  the  hemiplegic  form  the  patient  often  reaches  adult  life, 
and  if  his  intelligence  is  not  defective  and  he  has  no  epilepsy  the 
motor  trouble  improves  a  great  deal  and  he  may  live  a  long  and  use- 
ful life.  If  epilepsy  and  mental  defect  are  present,  there  ensues 
eventually  a  further  mental  deterioration,  and  such  subjects  rarely 


DISEASES   OF   THE    BRAIN.  443 

live  much  beyond  the  period  of  adolescence,  or  if  they  do  they  pass 
into  the  asylums  for  the  idiotic  and  epileptic.  The  diplegic  and 
paraplegic  cases  have  a  much  worse  prognosis  both  as  to  duration  of 
life  and  as  to  improvement  in  symptoms,  except  occasionally  the 
type  described  above  as  cerebral  spastic  paraplegia  or  Little's  dis- 
ease. The  degree  of  intelligence  and  the  absence  of  epilepsy  are 
the  two  factors  which  measure  the  seriousness  of  these  cases,  as  they 
do  those  of  the  hemiplegias.  As  regards  the  significance  of  individual 
symptoms,  the  post-hemiplegic  movements  have  a  bad  import;  the 
presence  of  a  microcephalic  head  or  of  decided  marks  of  degenera- 
tion is  unfavorable. 

Treatment. — The  treatment,  so  far  as  the  paralysis  is  concerned, 
is  largely  mechanical.  The  patient  is  benefited  by  occasional  courses 
of  electrical  treatment  which  stimulate  somewhat  the  nutrition  and 
functions  of  the  muscles.  Massage  and  stretching  of  the  con  frac- 
tured tendons  and  limbs  also  are  helpful  in  my  experience.  The 
orthopaedic  surgeon  is  able  to  render  valuable  assistance  by  occa- 
sional overstretching  the  contractured  limbs  and  placing  them  in 
splints.  Tenotomy  may  also  be  resorted  to  with  advantage,  as  I 
have  had  occasion  to  see.  The  child  should  be  encouraged  above 
all,  however,  to  use  the  limb  as  much  as  possible.  He  should  be 
taught  gymuastic  exercises;  running,  walking,  and  bicycle  riding 
are  all  measures  which  give  great  help.  When  the  child's  intelli- 
gence is  good  and  there  is  little  or  no  epilepsy,  a  great  deal  can  be 
expected  in  the  way  of  improvement  as  the  child  grows  older. 

So  far  as  the  epilepsy  is  concerned,  it  should  be  treated  on  the 
same  principles  as  idiopathic  epilepsy,  except  that  great  care  should 
be  had  in  the  use  of  the  bromides ;  a  thorough  test  must  be  made  in 
order  to  determine  how  much  of  this  drug  will  suppress  the  fits,  and 
then  its  use  must  be  graduated  in  the  future  in  accordance  with  the 
knowledge  thus  obtained.  The  mental  defects  of  the  child  can  be 
helped  only  by  proper  training  of  the  body  and  careful  education  of 
the  mind.  The  question  of  operative  interference  in  these  cases  has 
of  late  excited  much  attention.  A  priori  it  would  not  seem  as 
though  surgical  interference  could  do  good  in  relieving  conditions 
in  which  there  is  destroyed  or  atrophic  tissue.  Still  the  subject 
must  be  dealt  with  empirically,  and  there  have  been  some  results 
which  show  that  apparently  a  relief  is  obtained  in  a  few  cases  by 
trephining  the  skull  or  by  Lannelongue's  operation  of  craniectomy. 
If  there  is  no  microcephalus,  if  the  case  is  one  of  hemiplegia  with 
imbecility  and  epilepsy,  the  surgeon  should  simply  make  an  ex- 
ploratory opening.  If  he  then  finds  any  evidences  of  compression 
from  the  presence  of  a  cyst,  this  may  be  very  cautiously  opened. 


444  DISEASES   OF   THE   NERVOUS   SYSTEM. 

If  there  is  microcephalus,  the  linear  craniectomy  is  the  operation 
which  is  indicated.  In  all  cases,  in  operating  on  children  it  has 
been  found  that  it  is  imperative  that  the  operation  be  made  as 
short  as  possible,  and  that  as  little  be  done  at  any  single  operation 
as  is  consistent  with  the  indications. 


CHAPTER  XX. 

TUMORS   OF   THE   BRAIN— SYPHILIS. 

The  kinds  of  tumor  found  in  the  brain  are  tubercle,  syphiloma, 
glioma,  and  sarcoma,  which  are  the  common  forms;  myxoma,  car- 
cinoma, fibroma,  osteoma,  cholesteatoma,  lipoma,  psammoma,  neu- 
roma; vascular  tumors  including  aneurisms ;  echinococcus,  andcysti- 
cercus.  In  fact,  all  forms  of  new  growths  are  found  in  the  brain ;  but 
the  infections  granulomata,  tubercle  and  gumma,  and  the  sarcomatous 
type  of  tumors  are  the  most  common.  As  compared  with  other 
organic  diseases  of  the  central  nervous  system,  brain  tumors  are 
rare. 

^Etiology. — Brain  tumors  affect  males  oftener  than  females,  the 
ratio  being  about  as  two  to  one  (644 :  320) .  Sarcomata  alone  seem  to 
affect  females  about  as  often  as  males.  Brain  tumors  occur  with  about 
equal  frequency  throughout  all  ages  of  life  up  to  about  fifty;  one- 
third  occur  under  the  age  of  twenty  (Gowers).  During  childhood 
tumors  are  about  equally  distributed  throughout  all  ages  (Starr). 
One-half  of  all  the  tumors  of  childhood  are  tuberculous ;  after  this 
come  gliomata  and  sarcomata.  The  gumma,  glioma,  and  sarcoma 
begin  to  be  more  frequent  after  the  age  of  twenty.  Sarcoma  and 
especially  cancer  occur  in  the  middle  and  later  ages  of  life ;  but 
brain  tumors  of  any  kind  are  extremely  rare  after  the  age  of  sixty. 

To  sum  up  in  tabular  form,  the  relative  frequency  of  the  different 
kinds  of  tumors  with  regard  to  age  is  shown  in  the  following: 

Childhood,     .....  tubercle,  parasites. 

Early  life,     .....  gumma,  glioma,  parasites. 

Early  and  middle  life,  .         .  sarcoma,  glioma,  and  gumma. 

.Middle  ami  late  life,       .         .         .  sarcoma,  gumma,  cancer. 

Heredity  has  a  slight  influence  in  predisposing  to  brain  tumors. 
Blows  on  the  head  and  other  forms  of  injury  to  the  cranium  are 
exciting  causes  in  a  small  proportion  of  cases. 

Symptoms. — The  symptoms  of  brain  tumors  vary  extremely  in 
accordance  with  the  location,  the  kind  of  tumor,  the  rapidity  of 
growth,  and  the  age  of  the  patient.  The  general  course  of  a  case 
of  brain  tumor  in  an  adult  is  somewhat  as  follows:  The  patient 
first    notices   a  headache   which   is   intense   and    persistent,    and 


446  DISEASES    OF   THE   NERVOUS    SYSTEM. 

which  has  exacerbations  of  frightful  severity.  With  the  headache 
or  between  the  attacks  vomiting  occurs,  which  is  often  not  accom- 
panied by  any  nausea.  Sensations  of  vertigo,  annoying  pares- 
thesias, and  convulsive  movements  affecting  one  or  more  extremities 
develop,  and  there  may  even  be  general  convulsions.  The  patient 
finds  that  his  eyesight  is  weak  and  progressively  deteriorates. 
The  mind  becomes  more  or  less  disturbed,  the  mental  processes  are 
dull  and  slow,  a  feeling  of  hebetude  and  incapacity  to  attempt  any 
mental  exertion  is  present.  As  the  disease  progresses  the  intense 
pains  and  vomiting  produce  weakness  and  emaciation.  Paralyses 
of  various  kinds  develop.  Blindness  may  ensue.  Convulsions  of 
a  local  or  general  character  become  more  frequent,  and  finally  the 
patient  becomes  bedridden  and  helpless. 

The  course  of  the  disease  is  not  a  steady  one,  there  being  often 
slight  remissions,  or  there  may  be  periods  when  progress  seems  to 
be  arrested.  After  a  period  of  time  varying  from  one  to  four  or  five 
years  death  occurs  from  exhaustion  or  some  intercurrent  malady. 

The  symptoms  thus  very  briefly  outlined  are  divided  into  gen- 
eral and  focal.     The  general  symptoms  are : 

Headache, 

Vertigo, 

Vomiting, 

Optic  neuritis, 

Mental  defects. 

Besides  these  there  may  be  general  convulsions  and  speech  dis- 
turbances. 

Headache  occurs  in  from  one-half  to  two-thirds  of  the  cases ;  it 
is  very  severe  and  the  pains  are  of  a  boring  or  lancinating  character ; 
they  are  so  horrible  that  they  often  lead  the  patient  to  think  of  sui- 
cide. The  pains  are  sometimes  periodical,  occurring  every  night  or 
every  other  day,  and  suggest  by  their  perodicity  a  malarial  character. 
They  are  located  sometimes  in  the  brow  or  in  the  occiput,  while 
sometimes  they  are  diffused  all  over  the  head ;  they  are  rather  more 
frequent  than  otherwise  in  the  neighborhood  of  the  tumor.  They  are 
more  frequent  with  cerebellar  tumors  than  with  those  located  any- 
where else.  Pains  are  also  frequent  with  tumors  of  the  mid-brain 
and  of  the  cerebral  hemispheres.  They  are  less  frequent  with  tu- 
mors situated  in  the  peduncles  and  at  the  base  of  the  brain.  The 
pains  are  due  to  the  increased  intracranial  pressure  and  to  irritation 
of  the  membranes  of  the  brain  by  the  encroachment  upon  them  of 
the  new  growth.  Headache  occurs  in  about  the  same  proportion  in 
children  and  adults,  and  it  does  not  seem  to  bear  much  relation  to 
the  kind  of  tumor,  although  the  pains  are  generally  less  with  the 


TUMORS   OF   THE    BKAIX — SYPHILIS.  447 

gliomata,  and  they  are  more  frequent  with  rapidly  growing  tumors 
whatever  their  character.  With  the  pains  there  is  often  a  local 
tenderness  of  the  scalp  and  cranium  which  may  be  elicited  by  per- 
cussion, and  in  most  cases  there  is  greater  tenderness  in  that  part 
of  the  cranium  lying  over  the  tumor. 

Vomiting  is  a  symptom  which  is  almost  as  frequent  as  head- 
ache. The  vomiting  is  often  of  a  projectile  character  and  not  ac- 
companied by  much  nausea.  Vomiting  occurs,  as  does  headache, 
more  frequently  with  cerebellar  tumors.  It  is  associated  with  rap- 
idly growing  tumors  such  as  syphilitic  or  tuberculous  neoplasms. 

Vertigo  is  a  general  symptom  which  occurs  in  from  one-third  to 
one-half  of  the  cases.  The  vertigo  may  be  slight,  such  as  is  often 
felt  from  ordinary  causes.  Occasionally  it  is  very  severe  and  ac- 
companied by  forced  movements.  The  severer  forms  and  those 
associated  with  forced  movements  occur  with  tumors  of  the  cerebel- 
lum and  the  parts  closely  connected  with  it. 

Optic  neuritis  is  one  of  the  most  frequent  and  important  of  all 
the  general  symptoms  of  brain  tumor;  it  occurs  at  some  period  of 
the  disease  in  at  least  four-fifths  of  the  cases,  more  frequently  in 
cerebellar  tumors  and  in  those  of  the  mid-brain  and  great  basal 
ganglia.  It  is  rare  in  tumors  of  the  medulla.  It  is  less  frequent 
and  marked  in  the  slow-growing  tumors.  The  neuritis  may  run  a 
somewhat  rapid  course  and  then  improve  a  great  deal  or  even  for  a 
time  disappear ;  but  ordinarily  the  course  is  progressive  and  it  ends 
eventually  in  an  atrophy  of  the  optic  nerve.  Hence  the  examina- 
tion of  the  eyes  in  brain  tumors  should  be  made  a  number  of  times 
in  order  to  note  the  progress  of  the  trouble.  Primary  atrophv  of 
the  optic  nerve  does  not  occur  in  brain  tumors.  The  inflammation 
almost  always  affects  both  nerves,  but  it  may  begin  with  one  and 
subsequently  affect  the  other. 

Mental  defects  are  almost  always  present  in  tumors  of  the  brain. 
These  defects  consist  in  a  slowness  of  the  mental  processes,  a  condi- 
tion of  hebetude,  a  tendency  to  attacks  of  somnolence,  and  sometimes 
a  peculiar  childishness  and  silliness  or  peculiar  mental  irritability. 
The  memory  is  also  usually  somewhat  weakened  and  the  power  of 
attention  lessened.  Such  psychical  defects  are  more  frequent  with 
tumors  of  the  frontal  lobes  and  more  frequent  also  with  large  tumors. 

General  convulsions  occur  in  about  one-fourth  of  the  cases  and 
more  frequently  when  the  tumors  are  situated  in  the  cerebral  hemi- 
spheres and  cortex.  There  may  be  also  apoplectiform  attacks,  from 
which  the  patient  recovers  in  the  course  of  a  few  days  or  weeks. 
More  rarel}'  there  is  a  genuine  apoplexy  from  the  bursting  of  a 
blood-vessel  in  the  neighborhood  of  the  tumor. 


448  DISEASES    OF    THE    NERVOUS   SYSTEM. 

The  speech  disturbances  are  most  marked  in  tumors  which  affect 
the  pons  and  medulla  and  the  origin  of  the  cranial  nerves.  Such 
speech  disturbances,  when  characteristic,  are  shown  by  a  confluent 
articulation;  that  is  to  say,  the  patient  runs  the  syllables  together. 

The  cranial  temperature  in  brain  tumors  is  in  most  cases  some- 
what raised  as  compared  with  the  normal  (Gray,  Mills,  and  Lloyd). 
The  elevation  may  be  several  degrees  above  the  normal.  The  nor- 
mal average  scalp  temperatures  (Gray)  are  from  92°  to  94.5°  F., 
being  somewhat  higher  over  the  frontal  and  parietal  than  over  the 
occipital  regions.  In  brain  tumors  the  temperature  has  been  found 
raised  to  95°,  96°,  and  98°.  The  value  of  thermometric  observa- 
tions, however,  in  the  symptomatology  of  brain  tumors  is  somewhat 
doubtful,  owing  to  the  variability  in  the  normal  temperature  and 
the  difficulty  of  getting  accurate  records. 

Focal  Symptoms. — Having  by  a  study  of  general  symptoms 
arrived  at  a  fairly  certain  diagnosis  as  to  the  presence  of  a  tumor, 
it  is  necessary  to  corroborate  the  diagnosis  and  to  localize  the  lesion 
by  an  examination  of  the  symptoms  which  are  the  result  of  irrita- 
tion or  destruction  of  certain  particular  parts  of  the  brain;  these 
are  called  the  focal  symptoms.  For  purposes  of  special  or  local 
diagnosis  we  divide  the  brain  into  the  following  parts  or  areas 
(Knapp) :  1.  The  prefrontal,  which  includes  all  that  part  lying 
in  front  of  a  line  that  extends  from  the  upper  end  of  the  ascending 
branch  of  the  fissure  of  Sylvius  directly  up  at  right  angles  to  a 
horizontal  line  between  the  frontal  and  occipital  poles  of  the  brain 
(see  Fig.  211).  This  region  includes  probably  centres  for  the  move- 
ment of  the  head  and  eyes,  but  it  is  chiefly  concerned  with  the 
higher  intellectual  processes ;  its  under  surface  lies  on  the  orbital 
plate  of  the  frontal  bone  and  upon  the  right  olfactory  lobes.  2. 
The  central  region,  which  is  bounded  in  front  by  the  vertical  line 
just  described,  behind  by  a  line  passing  down  from  the  anterior  end 
of  the  parietal  fissure  to  the  fissure  of  Sylvius,  and  above  by  a  line 
that  bounds  posteriorly  the  postcentral  convolution.  3.  The  parie- 
tal lobe.  4.  The  occipital  lobe.  5.  The  temporal  or  temporo-sphe- 
noidal  lobe.  6.  The  corpus  callosum.  7.  The  great  basal  gan- 
glia and  capsules.  8.  The  corpora  quadrigemina,  deep  marrow,  and 
pineal  gland.  9.  The  crura  cerebri.  10.  The  pons  and  medulla. 
11.  The  cerebellum.  12.  The  basal  surface  of  the  brain.  The 
boundaries  of  most  of  these  areas  are  indicated  better  by  the  figure 
than  by  a  description.  They  correspond  to  some  extent  with  the 
cerebral  lobes,  but  not  entirely  so,  since  the  frontal  and  parietal 
lobes  divide  between  them  the  central  area. 

1.  Tumors  of  the  prefrontal  area.     Tumors  in  this  area  often 


TUMORS    OF    THE    BKAIN — STPHIMB. 


U9 


show  no  particular  localizing  symptoms,  and  this  part  of  the  brain 
is  consequently  put  down  as  a  latent  one;  nevertheless,  in  a  good 
proportion  of  cases  tumors  here  produce  peculiar  mental  disturb- 
ances that,  taken  in  conjunction  with  the  general  symptoms,  enable 
us  to  make  a  local  diagnosis.  The  symptoms  are  peculiar  mental 
hebetude,  childishness,  irritability,  often  a  kind  of  silliness  and 
emotional  weakness,  a  tendency  to  laugh  and  cry  and  to  get  angry 
at  trifling  causes.  The  entire  character  and  temperament  of  the 
man  are  sometimes  changed.      Besides  this,  owing  to  implication  of 

Localized  spasms  and  epilepsy  with  a  neory 
auis,  local  palsies,  slight  anaesthesia ,  motor 

aphasia,  agraphia. 


Mental  dulness, 
irritability,  child- 
ishness, lack  of 
Of  atten 
Hon;  later,  motor 
spasm  or  paraly- 
sis, anosmia,  eye 
symptoms,  hys- 
teria. 


Word  deafnes- 
deafnes-. 
w<  symptoms. 


Muscular  anaesthesia, 

apraxia,  oculo-motor 

m  pto  me,  word 

blindness.     With 

sp  lesions,  an» 

sthesia. 


H  e  m  i  a  n  opt»UV 
word  blindiiesa, 
soul  b  I  in  dness. 
Witii deep  lesions, 
anaesthesia. 


i  vn-lii  liar  ataxia, 
vertigo,  vomiting, 
movements, 
occipital     headache; 
later,    bulbar    symp- 
toms. 


i  alysia  ol  tongue 
and  limbs;  bulbar palsj 

Fig.  214.— Showing  the  Focal  Symptoms  of  Brain  Tuiiobs. 

the  olfactory  nerve,  there  may  be  loss  of  the  sense  of  smell  on  one 
or  both  sides;  implication  of  the  optic  nerves  will  cause  hemianopsia 
and  optic  neuritis.  If  the  tumor  involves  the  orbit  there  will  be 
paralyses  of  the  ocular  muscles  and  protrusion  of  the  globe  of  the 
If  the  tumor  grows  backward  there  is  gradual  invasion  of 
motor  centres  with  irritation,  showing  itself  by  spasms,  convulsions, 
and  later  by  pa  rah 

2.  Tumors  of  the  central  region.  Tt  is  in  this  area  that  we  are 
often  able  to  make  the  closest  and  most  accurate  diagnosis  of  the 
localization  of  new  growths,  owing  to  their  involvement  of  the  differ- 
ent motor  centres.  Through  this  involvement  these  centres  are  at 
first  irritated,  with  the  result  Of  producing  l"<al  spasms  or  Jackso- 
29 


450  DISEASES   OF   THE    NERVOUS    SYSTEM. 

nian  epilepsy.  Such  spasms  are  often  preceded  by  sensory  symp- 
toms or  aura?.  As  the  tumor  grows  the  area  of  involvement  becomes 
larger,  spasms  become  more  diffused,  and  general  convulsions  may 
finally  appear,  with  hemiplegia.  The  motor  disturbances  are  not 
infrequently  accompanied  by  sensory  disorders.  These  may  be 
simply  feelings  of  numbness  or  prickling,  which  either  are  perma- 
nent or  simply  precede  spasms,  or  there  may  be  hemiansesthesia 
of  a  moderate  degree  to  pain,  touch,  and  temperature.  The  mus- 
cular sense  also  may  be  somewhat  involved.  In  cases  of  slight 
sensory  involvement  the  capacity  for  localizing  sensations  seems  to 
be  most  implicated.  Besides  the  symptoms  mentioned,  there  may 
also  be  motor  aphasia  and  agraphia.  The  exact  localization  must 
be  worked  out  with  the  help  of  the  figures  and  descriptions  given 
under  anatomy. 

3.  Tumors  of  the  parietal  area.  The  symptoms  produced  by  tu- 
mors in  this  area  may  be  very  slight.  The  most  characteristic  are 
disturbances  of  muscular  sense,  which  occur  when  the  supramargi- 
nal  gyrus  is  affected,  and  word  blindness,  which  occurs  when  the 
angular  gyrus  and  inferior  lobule  are  affected.  When  the  tumor 
is  higher  up  near  the  longitudinal  fissure,  the  muscles  of  the  lower 
limbs  may  be  involved,  and  if  the  tumor  encroaches  upon  the  central 
area  spasms  and  paralyses  of  various  muscular  groups  ensue.  The 
cortical  representation  of  the  third  nerve  is  thought  to  be  in  the 
neighborhood  of  the  angular  gyrus,  and  some  cases  have  been  re- 
ported in  which  paralysis  of  this  nerve  resulted  from  tumors  in  that 
area. 

4.  Occipital  lobes.  Tumors  in  this  region,  if  situated  in  the 
cuneus  and  first  occipital  convolution,  produce  homonymous  hemi- 
anopsia. If  the  tumor  involves  the  other  parts  of  the  occipital  lobe 
and  the  cuneus  is  not  seriously  involved,  there  may  be  a  condition 
known  as  soul  blindness  or  incapacity  to  understand  the  nature  of 
the  things  which  one  sees.  If  the  tumor  extends  up  chiefly  toward 
the  angular  gyrus,  there  may  be  word  blindness,  along  with  some 
hemianopsia.  If  the  tumor  extends  farther  forward  into  the  parie- 
tal lobe,  there  may  be  hemianesthesia,  hemiataxia,  and  perhaps  a 
little  hemiplegia  owing  to  involvement  of  the  fibres  of  the  internal 
capsule. 

5.  Temporal  area.  The  temporal  or  temporo-sphenoidal  area 
on  the  right  side  is  very  nearly  a  latent  one.  On  the  left  side 
tumors  involving  the  posterior  part  of  the  first  and  upper  posterior 
part  of  the  second  temporal  convolution  produce  word  deafness. 
Tumors  in  either  lobe  when  large  and  extending  well  down  toward 
the  base  may  produce  attacks  of  vertigo  or  forced  movements,  owing 


TUMORS  OF  THE  BRAIX — SYPHILIS.  451 

probably  to  irritation  of  the  internal  ear.  Tumors  that  involve  the 
hippocampal  convolution  and  the  uncus  may  produce  perhaps  some 
disturbances  in  the  senses  of  smell  and  taste. 

6.  Tumors  of  the  corpus  callosum.  Tumors  situated  in  this 
area  are  very  rare.  Their  symptoms  have  been  thought  to  be 
somewhat  characteristic;  but  in  the  writer's  experience  they  corre- 
spond closely  with  tumors  situated  in  the  third  ventricle  and  lateral 
ventricles  of  the  brain;  in  other  words,  tumors  which,  beginning  in 
the  central  parts  of  the  brain,  gradualty  exteud  outward  toward  the 
periphery.  The  symptoms  credited  to  tumors  of  the  corpus  callo- 
sum are,  first,  the  general  sympoms  of  brain  tumor,  to  which  there 
are  superadded  a  gradually  developing  hemiplegia  with  later  a  para- 
plegia. At  the  same  time  there  is  a  great  deal  of  mental  dulness, 
stupidity,  and  drowsiness;  the  patient  often  sits  for  hours  mute, 
refusing  to  speak,  or  lies  in  a  half-somnolent  condition.  There  are 
no  paralyses  of  the  oculomotor  nerves  or  of  the  other  cranial  nerves. 
There  is  no  anaesthesia.  The  disease  gradually  progresses  and  the 
patient  dies  in  coma. 

7.  Tumors  of  the  great  basal  ganglia  and  the  capsule  (the  optico- 
striate  region).  The  general  symptoms  of  tumors  of  this  region 
resemble  in  many  respects  those  of  tumors  of  the  corpus  callosum. 
The  stupidity,  however,  may  be  less  marked.  There  is  usually  a 
progressive  hemiplegia  which  may  be  accompanied  by  anaesthesia 
and  sometimes  by  choreic  movements,  if  the  tumor  involves  the 
optic  thalamus  and  adjacent  part  of  the  capsule.  Tumors  of  the 
caudate  nucleus  alone  and  of  the  lenticular  nucleus  alone  seem  to 
give  rise  to  no  special  symptoms,  and  these  regions  are  regarded  as 
latent.  Tumors  of  the  anterior  three-fourths  of  the  optic  thalamus 
alone  may  cause  no  special  symptoms,  but  in  some  cases  there  oc- 
cur peculiar  choreic  or  athetoid  movements.  These,  however,  are 
probably  due  to  irritation  of  the  fibres  of  the  internal  capsule.  If 
the  tumor  involves  the  posterior  part  of  the  optic  thalamus  and  ad- 
jacent areas,  there  will  be  a  hemianopsia,  which  may  be  distinguished 
from  the  hemianopsia  due  to  lesions  in  the  occipital  lobe  by  the 
presence  of  the  herniopio pupillary  reaction;  that  is  to  say,  a  ray  of 
light  thrown  in  upon  the  insensitive  part  of  the  retina  will  not  pro- 
duce a  reflex  contraction  of  the  pupil. 

8.  Tumors  of  the  corpora  quadrigemina,  deep  marrow,  and 
pineal  gland.  The  characteristic  symptoms,  as  shown  by  Xoth- 
nagel,  of  tumors  of  this  region  are  inco-ordimition,  forced  move- 
ments, and  oculo-motor  palsies.  Together  with  these  there  may  be 
hemianopsia  or  blindness  due  to  destruction  of  the  primary  optic; 
centres.     It  is  possible  that  some  degreee  of  deafness  or  hemideaf- 


452 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


ness  may  be  produced  by  the  involvement  of  the  posterior  tubercles 
of  the  corpora  quadrigemina. 

9.  Tumors  of  the  cms.  Tumors  of  the  crura  cerebri  are  ex- 
tremely rare.  When  present,  they  cause  hemiplegia  and  perhaps 
a  hemianesthesia,  "with  paralysis  of  the  third  nerve  upon  the  same 
side  as  the  lesion;  in  other  words,  a  crossed  paralysis  (Fig.  215,  M). 

10.  Tumors  of  the  pons  and  medulla.     Tumors  in  this  area  nec- 


Fig.  x'l").—  Showing  the  Mechanism  op  Crossed  Paralysis.  Lesion  at  M  causes 
paralysis  of  third  nerve,  lesion  at  F  paralysis  of  fifth  nerve  with  hemiplegia  of  opposite 
side.     (After  Van  Gehuchten.) 

essarily  produce  very  varying  symptoms  in  accordance  with  their 
size  and  location.  If  the  tumor  is  in  the  pons  it  will  cause,  if  situ- 
ated high  up,  a  palsy  of  the  third  nerve  on  one  side  and  hemiplegia 
on  the  opposite  side.  If  lower  down  there  may  be  a  palsy  of  the 
fifth  nerve  on  one  side  and  hemiplegia  on  the  other  side  (Fig.  215,  F). 
If  the  tumor  is  extensive  it  may  produce  not  oidy  a  hemiplegia,  but  a 
hemianaesthesia.  If  situated  somewhat  superficially  and  on  the  lat- 
eral edge  of  the  pons  involving  the  peduncles,  there  will  be  forced 
movements  of  the  body,  either  toward  or  from  the  seat  of  the  lesion. 


TtTJTORS   OF   THE    BRAIN — SYPHILIS.  153 

If  the  tumor  is  in  the  medulla  it  will  produce  hemiplegia  and  hemi- 
anaesthesia,  with  paralysis  of  the  hypoglossal  nerve  or  perhaps  some 
other  cranial  nerves  upon  the  same  side  (Fig.  215,  II).  If  large  and 
involving  both  sides  of  the  medulla,  there  may  be  the  general  symp- 
toms of  a  progressive  bulbar  paralysis.  One  peculiarity  of  tumors 
situated  in  the  pons  is  that  they  sometimes  produce  a  conjugate 
deviation  of  the  eyes  which  is  away  from  the  side  of  the  lesion.  In 
this  respect  the  symptoms  differ  from  conjugate  deviation  produced 
by  lesion  in  the  cerebral  hemispheres,  in  which  the  head  and  eyes 
are  turned  toward  the  side  of  the  lesion. 

11.  The  general  symptoms  of  tumors  of  the  cerebellum  are,  us  we 
have  already  said,  more  pronounced  than  those  of  tumors  of  other 
regions;  we  more  frequently  have  headache,  vomiting,  vertigo,  and 
optic  neuritis  from  neoplasms  here.  If  the  tumor  is  situated  in  the 
lateral  Jobes  of  the  cerebellum,  no  localizing  symptoms  develop  until 
the  tumor  becomes  very  large  so  that  it  presses  upon  the  medulla  or 
other  adjacent  regions.  When  the  tumor  is  in  the  middle  lobe  a  pe- 
culiar ataxia  develops,  known  as  cerebellar  ataxia.  The  gait  of  the 
patient  is  a  reeling  one  like  that  of  a  drunken  man,  or  in  walking 
he  takes  short  steps  and  spreads  his  legs  as  if  in  fear  of  falling. 
This  has  been  called  the  titubating  gait.  Besides  this,  severe  forced 
movements  may  occur  which  usually  throw  him  sideways  or  perhaps 
forward,  very  rarely  backward.  Secondary  symptoms  from  pressure 
on  the  medulla  often  develop  in  tumors  of  the  middle  lobe,  such 
symptoms  being  glycosuria  and  disturbance  of  the  functions  of  the 
cranial  nerves.  Late  in  the  disease  hemiplegia  and  paraplegia  and 
bulbar  symptoms  may  develop  from  extreme  pressure.  There  may 
be  also  hydrocephalus  due  to  pressure  on  the  veins  of  Galen  and 
obstruction  of  the  return  flow  of  blood  from  the  central  arteries  of 
the  brain. 

12.  Tumors  of  the  base  of  the  brain.  Tumors  situated  in  the 
anterior  fossa  produce  symptoms  very  much  like  those  described 
under  the  head  of  tumors  of  the  prefrontal  area,  but  there  is  neces- 
sarily destruction  of  the  olfactory  lobe  and  there  is  more  apt  to  be 
involvement  of  the  optic  and  oculo-motor  nerves  and  of  the  tissues 
of  the  orbit. 

Tumors  of  the  middle  fossa.  Tumors  sometimes  involve  the 
hypophysis.  Such  condition  has  been  found  in  cases  of  acromegaly ; 
but  on  the  other  hand  a  number  of  tumors  of  this  region  ha\  e  \vru 
described  in  which  none  of  the  symptoms  of  acromegaly  were  pres- 
ent. Tumors  of  this  region  and  of  the  interpeduncular  space  pro- 
duce symptoms  such  as  would  naturally  result  from  pressure  on  the 
optic  chiasm,  and  it  is  mainly  the  early  presence  of  optic  neuritis 


454  DISEASES    OF   THE   NERVOUS   SYSTEM. 

and  of  peculiar  forms  of  hemianopsia  which  differentiates  lesions  in 
this  area  from  those,  in  the  anterior  fossa. 

Multiple  tumors.  About  one-seventh  of  all  brain  tumors  are 
multiple.  Hence  in  making  a  diagnosis  of  the  localization  of  tu- 
mors this  fact  must  be  borne  in  mind.  The  tumors  which  are  most 
frequently  multiple  are  tubercle,  cancer,  and  melanotic  growths. 

Pathology. — Tubercle  is  the  form  of  tumor  found  oftenest  in  chil- 
dren and  is  altogether  the  most  frequent  of  brain  tumors.  It  is  more 
often  located  in  the  cerebellum,  but  may  appear  in  the  pons  or  other 
parts  of  the  brain.  It  may  be  a  single  or,  as  it  is  then  called,  a 
solitary  tubercle,  or  there  may  be  a  multiple  growth.  The  tumor 
is  irregularly  round  in  shape  and  varies  in  diameter  from  one  and 
a  half  to  two  inches.  It  has  a  grayish-yellow  appearance  exter- 
nally ;  internally,  a  yellowish  or  cheesy  look.  It  is  not  vascular, 
but  is  often  surrounded  by  softened  or  inflamed  tissue.  There  may 
be  an  associated  meningitis.  The  tumors,  when  solitary,  usually 
start  from  the  central  parts  of  the  brain,  but  they  also  develop  on 
the  meninges  of  the  convexity,  particularly  in  the  parietal  region, 
and  sometimes  they  develop  also  at  the  base.  Tubercle  always 
arises  from  infection  by  the  tubercle  bacilli,  which  are  carried  by 
the  blood  to  the  brain.  The  tumors  develop  usually  from  some  in- 
fectious focus,  starting  in  a  blood-vessel  of  the  pia  mater.  Micro- 
scopically the  tumor  shows  the  ordinary  appearances  of  tuberculous 
growths.  It  contains  in  its  periphery  many  round  cells,  nuclei,  and 
giant  cells.  In  the  centre  there  is  usually  an  amorphous  substance, 
the  product  of  degeneration  and  the  breaking  down  of  the  ordinary 
substance  of  the  tumor.  The  characteristics  of  the  growth  are  the 
presence  of  the  round  cells  and  giant  cells,  the  caseation  and  soft- 
ening of  the  centre,  and  the  absence  of  vascularization,  with  the 
presence  of  the  bacilli. 

Syphiloma  or  gumma.  Gummatous  tumors  of  the  brain  are 
usually  associated  with  syphilitic  meningitis  or  some  other  form 
of  cerebral  syphilis,  such  as  endarteritis,  and  perhaps  inflammation 
of  the  cranial  nerve  roots.  Syphilitic  growths  are  usually  found 
upon  the  brain  surface,  oftenest  on  the  base,  next  upon  the  con- 
vexity of  the  frontal  and  central  convolutions.  The  process  appears 
either  in  the  form  of  a  somewhat  distinct  tumor  or  in  the  form  of  an 
irregular  thickened  exudate  lying  upon  the  surface  of  the  brain  and 
forming  what  is  called  gummy  meningitis.  The  gummata  may  at- 
tain great  size.  They  start  usually  from  the  pia  mater  and  are  due, 
as  in  the  case  of  tubercle,  to  the  irritative  action  of  some  infective 
organism.  The  gumma  is  irregular  in  shape;  it  has  a  somewhat 
rhick  grayish  periphery  and  often  a  yellowish  centre,  the  appear- 


TUMORS   OF   THE   BRAIN — SYPHILIS.  455 

ances  differing  with  the  age  of  the  tumor.  Microscopically  it  is 
found  to  consist  of  small  round  cells  and  spindle  cells  with  various 
broken-down  nerve-tissue  elements.  It  presents  in  the  interior  the 
evidence  of  cheesy  degeneration,  somewhat  like  that  in  tubercle,  but 
less  marked.  There  is  a  peculiar  development  of  fibrous  tissue  in  the 
syphilitic  growths  which  distinguishes  them  somewhat.  Besides  this, 
the  blood-vessels  are  numerous  in  the  periphery  and  show  evidences 
of  endarteritis  and  peri-arteritis.  The  distinctions  between  gumma 
and  tubercle  are  the  less  amount  of  cheesy  degeneration  in  the  centre 
of  the  former,  its  more  irregular  appearance,  the  presence  of  arteritis 
and  vascularization,  the  absence  of  giant  cells  and  of  tubercle  bacilli. 

Actinomycosis  is  a  form  of  infectious  tumor  which  sometimes 
extends  from  the  face  and  neck  into  the  brain,  leading  to  inflamma- 
tory processes,  however,  rather  than  to  true  tumors.  No  other  neo- 
plasms of  infectious  origin  attack  the  brain  unless  glioma  be  found 
to  be  of  that  nature. 

Glioma  may  occur  in  any  part  of  the  brain,  but  is  most  fre- 
quently found  in  the  cerebrum.  It  is  the  only  tumor  which  is  pe- 
culiar to  the  nervous  centres,  being  developed  from  the  neuroglia 
tissue  which  forms  the  supporting  structure  of  these  centres.  Gli- 
oma originates  in  the  white  matter  of  the  nerve  centre  and  not  from; 
the  membranes  or  fibrous  structures.  It  may  grow  to  a  very  large 
size  and  is  the  form  of  brain  tumor  which  becomes  the  largest. 
Gliomatous  tumors  measure  from  three  to  eight  or  more  centimetres 
in  diameter.  In  appearance  the  glioma  can  be  scarcely  distinguished 
from  the  brain  substance  itself,  but  usually  looks  like  either  pale  or 
congested  gray  matter,  or  it  may  have  a  yellowish  or  gelatinous  ap- 
pearance. The  tumor  is  very  vascular  and  it  may  show  the  results 
of  hemorrhages.  The  central  part  sometimes  breaks  down,  forming 
cavities  or  cysts.  The  tumor  may  grow  very  rapidly,  infiltrating 
the  normal  tissue.  In  these  cases  there  is  hardly  any  definite  boun- 
dary between  the  tumor  and  the  normal  tissue.  In  other  cases  the 
tumor  grows  slowly,  but  rarely  if  ever  becomes  encapsuled.  Micro- 
scopically it  is  found  to  consist  of  small  cells  with  delicate  fibrous 
prolongations,  these  being  the  glia  cells.  The  tumor  is  very  vascu- 
lar and  its  whole  appearance  is  suggestive  of  an  inflammatory  proc- 
ess rather  than  a  new  growth ;  the  inflammatory  process  being  one- 
in  which  the  neuroglia  tissue  reacts  to  the  inflammatory  irritant. 
Gliomata  may  undergo  certain  changes,  e.g.,  a  mucous  degeneration 
of  the  cells  takes  place,  forming  a  myxo-glioma.  When  there  is 
with  the  neuroglia-cell  proliferation  a  rich  proliferation  of  round 
cells  from  the  connective  tissue  it  is  called  a  glio-sarcoma.  When 
the  tumor  is  situated  near  the  surface,  involves  the  membranes,  and 


456  DISEASES    OF    THE    NEKYOUS    SYSTEM. 

grows  slowly,  with  an  increase  in  fibrous  tissue,  it  is  called  a  fibro- 
glioma.  When  the  gliomatous  growth  is  very  firm  and  hard,  the 
fibrous  portion  of  the  glia  tissue  predominates ;  it  constitutes  a  nod- 
ule such  as  is  found  in  multiple  sclerosis,  and  these  hard  gliomata 
are  sometimes  called  neuro-gliomata. 

Sarcoma.  The  sarcoma  and  its  various  modifications  form  per- 
haps the  most  important  and  almost  the  most  frequent  of  the  brain 
tumors.  The  sarcoma  is  a  tumor  of  connective-tissue  origin  j  it  de- 
velops, therefore,  from  the  brain  membranes  or  from  the  sheaths  of 
the  blood-vessels.  Sarcomas  may  be  single  or  multiple.  They  may 
be  of  all  shapes  and  they  grow  to  very  varying  sizes.  They  often 
develop  a  capsule.  They  may  be  either  primary  or  secondary. 
Their  growth  is  often  rapid.  [ffhey  are  white  or  grayish  in  appear- 
ance or  may  be  somewhat  yellowish,  dependent  on  the  predominance 
of  the  different  kinds  of  cells  and  blood-vessels.  Microscopically 
they  are  made  up  of  small  round  cells,  spindle  cells,  and  other  cells 
of  various  sizes  and  forms.  They  contain  often  considerable  fibrous 
tissue.  They  contain  blood-vessels,  but  are  not  richly  vascular. 
The  essential  characteristic  of  the  sarcoma  is  the  rich  development 
of  round  cells  and  spindle  cells;  in  other  words,  its  rich  cellular 
contents.  Sarcomata  are  peculiar  in  undergoing  many  modifications. 
Thus  sometimes  fibrous  tissue  develops  largely  and  the  tumor  is 
called  a  fibro-sarcoma;  sometimes  the  tumor  undergoes  mucous  de- 
generation and  is  called  a  myxo-sarcoma.  There  may  be  a  breaking 
down  of  the  centre  with  the  formation  of  cysts.  There  may  be  a 
development  of  pigment.  Not  infrequently  a  sarcomatous  process 
invades  a  glioma  and  we  have  a  mixture  of  a  sarcoma  and  glioma. 
Sarcomatous  tumors  sometimes  have  an  alveolar  structure.  These 
tumors  contain  endothelial  cells  derived  from  the  lymphatics  and 
are  called  endothelioma.  When  sarcomata  develop  from  the  dura 
mater  and  are  slow  in  growth  there  may  be  calcareous  deposits  in 
them  and  they  are  called  psammomata. 

The  fibroma  is  a  very  rare  brain  tumor,  unless  the  pacchionian 
bodies,  when  enlarged  and  hardened,  may  be  so  considered. 

Osteoma  is  not  particularly  rare,  developing  in  the  form  of  bony 
plates  in  the  dura,  falx,  or  tentorium.  Osteomata  in  the  brain 
substance  are  mere  pathological  curiosities. 

Enchondromata,  lipomata,  and  angiomata  are  rare  and  have  no 
practical  importance. 

Occasionally  neuromata  or  false  neuromata  are  found  developing 
on  the  roots  of  the  cranial  nerves. 

Cancer  is  relatively  a  very  rare  affection  of  the  brain,  especially 
as  a  primary  development.      It  usually  arises  from  the  membranes 


TUMORS    OF   THE    BRAIN — SYPHILIS. 


457 


of  the  brain.     Cancer  is  not  infrequently  multiple  and  is  usually  of 
the  soft  or  colloid  character. 

Parasitic  growths.  Parasitic  tumors  are  extremely  rare  in  this 
country.  The  only  forms  which  are  found  are  the  echinococcus 
and  the  cysticercus  cellulosse.  The  echinococcus  produces  hydatid 
cysts,  which  may  be  large  or  small,  few  or  many,  and  are  usually  all 
upon  the  surface  of  the  brain.  They  are  much  rarer  than  the  cysti- 
eerci.     These  form  cysts  which  are  usually  multiple,  slow  in  growth, 


Fig.  21tj.—  Ecmsococcrs  Cyst  of  the  Third  Ventricle. 

lie  upon  the  surface  of  the  brain  or  in  the  ventricles,  are  encapsuled, 
and  show  no  symptoms  (Pig.  210). 

Aneurisms  are  anatomically  tumors,  but  clinically  they  present 
some  special  symptoms  and  hence,  arc  described  separately. 

Diagnosis.  It  is  necessary  first  to  make  the  diagnosis  of  the 
presence  of  the  tumor,  next  of  its  location,  and  finally  of  its  nature. 
Che  existence  <>f  a  brain  tumor  is  determined  by  the  presence  of  the 
characteristic  general  symptoms — headache,  vomiting,  vertigo,  optic 
neuritis,  mental  disturbances,  and  progressive  course.  The  physi- 
cian must  bear  in  mind  the  possibilities  of  meningitis,  abscess,  lead 
poisoning,  hysteria,  and  paretic  dementia.  Very  often  a  localized 
basilar  meningitis  of  syphilitic  or  tuberculous  origin  simulates  closely 
the  presence  of  a  tumor.  Besides  the  general  points  referred  to,  in 
estimating  the  probabilities  of  the  existence  of  a  tumor  we  must 
bear  in  mind  the  age  of  the  patient  and  the  existence  of  a  tubercu- 
lous or  syphilitic  history,  the  history  of  an  injury,  of  local  tender- 


458  DISEASES   OF   THE   NERVOUS   SYSTEM. 

ness,  and  of  rise  of  cranial-surface  temperature,  and  the  presence 
of  some  new  growth  in  other  parts  of  the  body,  particularly  about 
the  neck  or  thorax  or  in  the  lungs. 

The  diagnosis  of  the  location  of  the  tumor  is  based  upon  the 
rules  already  given  in  regard  to  local  diagnosis.  The  diagnosis  of 
the  nature  of  the  tumor  can  often  be  made  and  should  be  attempted. 
In  children,  for  example,  the  chances  of  the  tumor  being  tuberculous 
are  very  great,  particularly  if  there  is  a  scrofulous  diathesis  or  tuber- 
culous disease  elsewhere.  Syphilitic  tumors  of  the  brain  are  almost 
always  accompanied  by  or  preceded  by  manifestations  of  external 
syphilis.  Gliomatous  tumors  occur  in  childhood  and  early  life.  They 
produce,  as  a  rule,  fewer  irritative  phenomena  and  are  accompanied 
by  remissions  and  by  apoplectic  or  pseudo-apoplectic  attacks  due  to 
the  vascular  nature  of  the  tumor.  Carcinomata  occur  late  in  life 
and  are  usually  secondary. 

Prognosis. — In  extremely  rare  cases  tumor  of  the  brain  appears 
to  stop  growing  and  become  encapsulated  and  atrophied.  Such 
tumors  are  of  a  tuberculous  or  syphilitic,  perhaps  sometimes  of  a 
sarcomatous  character.  As  a  rule,  the  brain  tumor  grows  steadily 
and  the  symptoms  of  the  disease  become  more  pronounced  until 
death  occurs.  The  prognosis  is  best  for  tubercle  in  children  and 
gumma  in  adults.  It  is  worse  in  those  cases  of  glioma  and  sarcoma 
which  have  a  rapid  course.  In  fact,  the  sooner  serious  symptoms 
develop,  the  more  rapid  the  general  development  of  the  disorder, 
the  sooner  does  a  fatal  termination  come.  The  disease  lasts  on  an 
average  two  or  three  years,  ranging  from  a  month  to  eighteen  years. 

Treatment.  —  Something  can  be  done  in  cases  of  tuberculous  tu- 
mors, syphilitic  tumors,  and  possibly  in  the  sarcomatous  variety. 
In  tuberculous  tumors  a  general  constitutional  and  strengthening 
treatment  must  be  resorted  to ;  fresh  air,  tonics,  and  a  large  amount 
of  food  being  the  main  reliance.  The  utility  of  any  form  of  tuber- 
culin is  as  yet  doubtful.  In  syphilitic  tumors  much  can  be  done  by 
the  usual  vigorous  anti syphilitic  treatment.  In  sarcomatous  tumors, 
if  they  are  suspected,  some  help  may  be  obtained  from  the  internal 
use  of  arsenic.  Symptomatically  we  must  give  such  drugs  as  anti- 
pyrin,  phenacetin,  antifebrin,  codeine,  and  perhaps  morphine  for  the 
relief  of  pain.  The  ice  cap  and  leeching  often  help  the  headache 
also.  Should  convulsions  develop  the  bromides  should  be  used,  just 
as  in  idiopathic  epilepsy. 

In  cases  in  which  the  location  of  the  tumor  can  be  made  out,  the 
question  of  surgical  interference  should  be  considered.  The  percen- 
tage of  cases  in  which  surgery  can  help  is  extremely  small.  It  will 
include  only  those  cases  in  which  the  tumor  can  be  located ;  of  those 


TUMORS    OF    THE    BRAIN — SYPHILIS.  459 

which  can  be  located,  only  those  which  are  in  an  accessible  region, 
and  finally,  of  those  which  are  in  an  accessible  region,  it  includes 
those  which  are  either  superficial,  or,  if  lying  in  the  brain  substance, 
are  more  or  less  encapsulated.  The  removable  tumors  of  the  brain 
amount  to  less  than  five  per  cent.  They  are,  in  particular,  the  sar- 
comatous, syphilitic,  and  tuberculous  tumors  lying  in  the  central  or 
occipital  areas.  In  many  cases  in  which  there  is  some  doubt  as  to 
the  localization  an  exploratory  trephining  is  justifiable,  and  in  a  few 
cases  in  which  it  is  known  that  the  tumor  cannot  be  removed  the 
trephining  for  the  simple  purpose  of  relieving  pressure  is  justifiable. 
It  is  probable  that  in  adults  some  tumors  from  the  anterior  and  mid- 
dle fossa  of  the  brain  can  be  removed.  In  children  tumors  cannot 
be  removed  successfully  from  the  cerebellum;  in  adults  it  is  pos- 
sible. Operations  for  tumors  should  be  undertaken  as  early  as 
possible ;  this  is  a  fact  on  which  too  much  stress  cannot  be  laid. 

INTRACRANIAL    AxEURISMS. 

Intracranial  aneurisms  are  of  two  kinds — "  miliary"  and  those 
of  large  size.  The  miliary  aneurisms  are  minute  dilatations  of  the 
vessels  and  are  always  multiple;  they  have  been  described  under 
the  head  of  cerebral  hemorrhage.  Large  aneurisms  affect  only  the 
large  cerebral  arteries  at  the  base  of  the  brain.  The  arteries  are 
affected  in  the  following  order:  middle  cerebral,  basilar,  internal 
carotid,  and  anterior  cerebral.  The  anterior  and  posterior  commu- 
nicating and  vertebral  arteries  are  occasionally  involved,  the  posterior 
cerebral  and  inferior  cerebellar  very  rarely  (Gowers). 

Etiology. — Males  are  affected  slightly  oftener  than  females. 
Aneurisms  occur  at  all  ages  from  ten  to  sixty;  before  ten  and  after 
sixty  they  are  extremely  rare.  Heredity  occasionally  plaj's  a  part 
in  predisposing  to  cerebral  aneurisms.  The  exciting  causes  are 
embolism,  especially  when  the  emboli  contain  microbes;  syphilitic 
disease,  injuries,  and  in  rare  cases  senile  degeneration. 

The  symptoms  are  very  indefinite;  they  resemble  to  a  consider- 
able extent  those  of  tumor  at  the  base  of  the  brain;  headache  and 
vertigo,  mental  dulness  and  irritation,  cranial-nerve  palsies,  and  oc- 
casionally hemiplegia  and  convulsions  are  noted.  Optic  neuritis  is 
rather  rare.  In  a  few  cases  the  patient  is  conscious  of  a  murmur  or 
recognizes  the  pulsating  sensation  in  the  head.  Sometimes  when  the 
aneurism  is  in  the  vertebral  artery  a  murmur  can  be  heard  bel 
the  mastoid  process  and  the  spinal  column  (Moser). 

The  diagnosis  is  often  difficult;  it  is  based  on  symptoms  of  tumor 
at  the  base  of  the  brain  pressing  on  cranial  nerves  and  on  motor  o: 
sensory  tracts.     The  effect  of  carotid  compression  should  be  tried. 


460  DISEASES    OF   THE   NERVOUS    SYSTEM. 

The  prognosis  is  not  good.  In  perhaps  the  majority  of  cases  a 
rupture  of  the  vessel  occurs  in  a  few  years ;  however,  rupture  is  not 
the  inevitable  event,  and  sometimes  the  disease  becomes  stationary 
or  undergoes  spontaneous  cure. 

The  treatment  of  the  disease,  if  it  can  be  recognized,  is  the  same 
as  that  for  aneurism  elsewhere  so  far  as  drugs  are  concerned ;  surgi- 
cally the  common  carotid  may  be  tied  and  perhaps  the  vertebral  if 
the  aneurism  is  believed  to  be  connected  with  that  artery  or  with 
the  basilar. 

Syphilis    of   the    Nervous    System. 

Syphilis  is  an  extremely  important  factor  in  the  causation  of  the 
organic  diseases  of  the  nervous  system.  Nervous  syphilis  makes 
up  over  ten  per  cent  of  all  the  hereditary  forms,  and  while  in  adult 
life  the  specific  virus  attacks  nerve  centres  relatively  less  often,  yet 
it  is  a  factor  whose  importance  is  very  great.  In  the  previous  de- 
scriptions of  nervous  diseases  we  have  referred  to  the  syphilitic  ele- 
ment in  connection  with  etiology  and  pathology ;  but  syphilis  produces 
upon  the  nervous  system  certain  forms  of  disease  which  are  charac- 
teristic, hence  it  is  best  to  take  a  brief  survey  of  the  effects  of  this 
infection  independently.  Syphilis  is  beyond  much  question  the 
result  of  an  infection  by  a  microbe,  and  the  result  of  the  activity  of 
this  microbe  upon  the  nervous  centres  is  to  produce  a  condition 
which  is  really  a  form  of  inflammation.  The  reader  can  best  un- 
derstand syphilitic  disorders,  therefore,  by  remembering  that  they 
are  all  forms  of  an  inflammation.  The  syphilitic  infiltration  is 
simply  an  exudative  inflammation  with  a  specific  exudate;  the 
syphilitic  gumma  is  a  deposit  of  this  exudation  analogous  some- 
what to  an  abscess.  Syphilis  attacks  chiefly  the  membranes  of  the 
brain  and  spinal  cord  and  the  blood-vessels  of  these  organs;  in  par- 
ticular the  base  of  the  brain  and  the  blood-vessels  that  supply  this 
region  are  affected.  Syphilis  acts  on  the  nervous  centres  in  four 
ways:  it  produces  meningeal  exudation  and  inflammation,  it  forms 
gummatous  tumors,  it  causes  arteritis,  and  it  leads  to  degenerations. 

The  first  three  processes  are,  however,  only  different  types  of 
exudative  inflammation,  so  that  we  have  in  reality : 

r  meningitis. 

1.  Exudative  syphilis       -j  gumma. 

(  arteritis. 

2.  Degenerative  syphilis  \  *>rain  ™*W** 

(  degeneration. 


TUMORS   OF   THE    BRAIN — SYPHILIS.  461 

Etiology. — A  neuropathic  constitution  probably  predisposes  to 
the  development  of  nervous  syphilis.  The  age  at  which  it  occurs 
most  frequently  is  between  twenty  and  forty,  but  it  may  occur  at 
all  periods  of  life  from  infancy  up.  It  attacks  men  oftener  than 
women  in  the  proportion  of  about  seven  to  one.  Hereditary  syphilis 
makes  up  about  three  per  cent  of  the  cases.  Inadequate  and  im- 
proper treatment  of  the  disease  at  first  probably  favors  the  develop- 
ment of  nervous  syphilis  later.  The  use  of  alcohol,  excesses  in  the 
way  of  severe  bodily  exercise,  severe  mental  strain,  and  overwork 
predispose  to  the  development  of  the  disease;  injuries  undoubtedly 
have  a  similar  effect.  The  time  after  the  infection  when  the  dis- 
ease is  most  apt  to  occur  is  the  third  year,  but  it  is  not  infrequent 
between  the  second  and  the  tenth  years,  and  it  is  possible  for  nerve 
syphilis  to  develop  from  within  a  few  months  up  to  thirty  years 
after  the  infection. 

Symptoms. — Sioee  syphilitic  changes  may  attack  any  part  of  the 
nervous  centres,  the  symptomatology  of  nerve  syphilis  is  necessarily 
a  varied  one.  The  reader  can  perhaps  best  understand  the  way  in 
which  the  disease  acts  by  having  presented  first  a  series  of  tables 
showing  on  the  one  side  the  clinical  symptoms,  on  the  other  the 
chief  anatomical  changes  that  underlie  them.  The  first  table  pre- 
sents the  symptoms  of  syphilis  of  the  brain,  which  is  unquestionably 
the  most  common  form.  The  next  table  shows  the  symptoms  of 
syphilis  of  the  cerebro-spinal  system,  a  form  which  ranks  second  in 
frequency.  Third  we  have  syphilis  of  the  spinal  cord  alone,  which 
is  somewhat  rarer,  and  last  and  rarest  of  all  we  have  syphilis  of  the 
nerves.  In  addition  to  these  four  forms  of  syphilitic  manifestation 
we  have  two  diseases  which  are  acknowledged  to  be  sequela?  of 
syphilis  and  which  are  called  post-syphilitic  degenerative  processes 
or  degenerative  syphilis. 

I. — Syphilis  of  the  Brain. 

Clinical  Symptoms.  Anatomical  Change. 

Severe  headache,  vomiting,  vertigo,  Gummatous  inflammation  of  the  base 

mental    dulness,    and    irritability,  involving  nerve  roots,  or  gumma- 

attacks  of  somnolence  or  coma,  con-  tous    inflammation    of    convexity, 

vulsions,  cranial-nerve  palsies, optic  arteritis,  and  phlebitis, 
neuritis,  hemiplegia,  polyuria,  am! 
polydipsia. 

II. — Ckkkuko  Si'iN.w,  Syphilis. 

Many  of  the  brain  symptoms  as  above,      Gummatous  basilar  meningitis;  dif- 
spastic  paraplegia  with  spinal  pains  fuse,      disseminated,     or    localized 

and  involvement  of  sphincters.  meningo-myelitis. 


462  DISEASES   OF   THE    NERVOUS    SYSTEM. 

III. — Spinal  Syphilis. 
Paraplegia    with    pains,    Brown-      Meningo-rnyelitis,  gumma,  localized 
Sequard  paralysis.  softenings    from    obliterative    ar 

Spastic  paraplegia  and  ataxia.  teritis. 

IV. — Syphilis  op  Nerves. 

Cranial-nerve    palsies,    cauda-equina      Root  neuritis,  gummatous  neuritis, 
symptoms,  local  palsies  of  periph- 
eral nerves. 

V. — Post-Syphilitic  Degenerative  Processes. 

Locomotor  ataxia  ;  general  paresis. 

Taking  up  these  different  forms  of  nerve  syphilis  in  order,  I  will 
give  some  further  details  with  regard  to  each  of  them. 

I.  Syphilis  of  the  brain  in  its  most  common  form  shows  itself 
by  a  gradual  development  of  severe  and  persistent  headache.  This 
is  usually  associated  with  vertigo,  sometimes  with  nausea  and  vom- 
iting. After  the  headache  has  developed  and  has  lasted  for  a  time, 
or  even  without  much  delay,  there  comes  on  sometimes  an  attack  of 
hemiplegia.  Preceding  the  hemiplegia,  or  in  some  cases  without 
the  hemiplegia,  there  are  paralyses  of  the  cranial  nerves,  more  es- 
pecially of  the  nerves  of  the  eye.  Optic  neuritis  is  someAvhat  fre- 
quent. There  may  be,  before  any  paralyses  develop,  attacks  of 
epileptic  convulsions,  either  general  or  partial.  Without  any  paral- 
yses or  with  simply  cranial-nerve  paralyses  there  may  develop  at- 
tacks of  somnolence  and  coma.  Even  if  such  attacks  do  not  appear 
the  patient  often  shows  a  mental  irritability  and  weakness,  a  slow- 
ness of  the  reasoning  process,  and  incapacity  to  fix  the  attention 
such  as  is  observed  in  connection  with  brain  tumors,  only  with 
nerve  syphilis  these  symptoms  are  not  usually  so  marked.  Polyuria 
and  polydipsia  are  symptoms  which  are  occasionally  met  with.  It 
will  be  seen  that  the  syphilitic  poison  produces  very  various  mani- 
festations when  it  attacks  the  brain.  The  characteristic  features 
are  this  variability  in  the  symptoms  and  their  remittent  character. 
Elaborate  systems  of  clinical  classification  might  be  made  out  of 
these  various  groups,  but  it  will  be  sufficient  for  the  present  pur- 
pose to  call  attention  to  the  fact  that  the  intense  headaches,  optic 
neuritis,  cranial-nerve  palsies,  attacks  of  somnolence  and  coma,  and 
hemiplegia  associated  with  some  of  the  foregoing  symptoms  are 
characteristic  of  most  of  the  forms.  The  reason  for  the  peculiar 
symptoms  in  brain  syphilis  is  manifest  when  it  is  known  that  the 
lesion  most  commonly  found  underlying  them  is  a  gummatous  men- 
ingitis which  has  a  special  predilection  for  the  base  of  the  brain. 
In  particular  it  seems  to  attack  the  interpeduncular  space  and  the 
neighborhood  of  the  optic  chiasm  and  the  surface  of  the  pons  Varolii. 


TUMORS    OF   THE    BRAIN — SYPHILIS.  463 

This  gummatous  meningitis  consists  of  a  syphilitic  inflammatory  ex- 
udate which  surrounds,  presses  upon,  and  injures  cranial  nerves, 
attacks  the  arteries  of  the  base,  producing  an  obliterating  arteritis 
and  consequent  softenings,  with  the  hemiplegia  which  is  so  often  a 
manifestation  of  the  disease.  Much  less  frequently  the  inflamma- 
tory process  attacks  the  convexity,  and  then  it  assumes  the  form  of 
a  gummatous  patch  which  produces  cortical  irritation  with  head- 
aches, mental  disturbances,  and  convulsions. 

II.  The  next  form  of  nervous  syphilis  is  the  cerebro-spinal.  In 
this  we  have  almost  exactly  the  same  conditions  and  symptoms  so 
far  as  the  brain  is  concerned;  but  in  addition  there  are  symptoms 
due  to  more  or  less  diffuse  syphilitic  inflammation  of  the  pia  mater 
of  the  spinal  cord.  The  syphilitic  process  often  extends  into  the 
spinal  cord,  producing  an  obliteration  of  the  arteries  and  softening 
with  the  symptoms  of  a  transverse  or  a  central  myelitis.  Thus  we 
have  combined  the  symptoms  of  cerebral  syphilis  and  paraplegia 
with,  as  a  rule,  considerable  pain  in  the  back,  produced  by  the 
involvement  of  the  meninges. 

III.  The  third  type  of  syphilis  is  the  spinal  form.  The  symp- 
toms in  spinal  syphilis  are  usually  those  of  a  transverse  myelitis, 
involving,  in  the  writer's  experience,  most  often  the  lower  part  of 
the  dorsal  and  upper  part  of  the  lumbar  cord.  This  myelitis  usu- 
ally comes  on  rather  slowly  with  the  ordinary  symptoms  of  a 
chronic  or  subacute  transverse  myelitis,  there  being  a  progressive 
paraplegia  with  spasticity  of  the  legs  and  a  good  deal  of  pain.  The 
condition  is  known  as  syphilitic  spinal  paralysis.  It  is  probable  that 
syphilis  is  a  much  more  frequent  factor  in  the  production  of  so-called 
transverse  myelitis  than  is  usually  supposed.  The  anatomical  proc- 
ess underlying  it  is  that  of  a  meningitis  which  passes  along  the 
septa  into  the  substance  of  the  cord,  involves  the  arteries  of  the 
cord,  and  produces  a  more  or  less  complete  softening  of  the  part. 
The  only  truly  inflammatory  process,  therefore,  is  that  which  is 
produced  in  the  meninges,  connective  tissues,  and  arteries.  The 
anatomical  changes  in  the  cord  substance  are  mainly  those  of  soft- 
ening with  reactive  inflammation.  Spinal  syphilis  ma}^  show  itself 
also  by  the  development  of  gummatous  nodules  which  grow  from  the 
meninges,  press  upon  the  cord,  and  produce  the  symptoms  of  a  spinal 
tumor.  Spinal  syphilis  may  also  develop  itself  in  three  or  four  dif- 
ferent foci,  producing  the  symptomatology  of  disseminated  myelitis. 

IV.  Syphilis  of  the  nerves.  Syphilis  rarely  affects  the  periph- 
eral nerves;  there  are,  however,  occasional  deposits  of  syphilitic 
exudate  producing  the  ordinary  symptoms  of  irritation  and  com- 
pression of  nerve,..     There  is  said  to  be  a  form  of  multiple  neuritis 


464  DISEASES   OF   THE    NERVOUS    SYSTEM. 

produced  by  syphilis,  but  its  actual  existence  has  not  yet  been  abso- 
lutely demonstrated.  Syphilis  has  been  known  to  attack  the  roots 
of  the  cranial  nerves,  producing  a  root  neuritis ;  and  it  is  very  apt 
to  attack  the  roots  of  the  spinal  nerves  when  the  spinal  membranes 
are  involved. 

V.  The  post-syphilitic  degenerative  processes  are  locomotor 
ataxia  and  general  paresis.  Occasionally  it  happens  that  the  syph- 
ilitic deposits  in  the  spinal  cord  may  produce  lesions  somewhat  like 
those  of  locomotor  ataxia,  and  in  this  case  there  will  be  a  train  of 
symptoms  which  also  resemble  this  disease.  In  true  locomotor 
ataxia,  however,  the  process  is  a  degenerative  not  an  exudative  one. 
The  syphilitic  poison  seems  so  to  affect  the  nervous  centres  as  to 
predispose  them  to  the  peculiar  degeneration  characteristic  of  tabes. 
Syphilis  may  also  produce  a  chronic  meningo-eucephalitis  which  will 
manifest  itself  by  symptoms  resembling  to  a  considerable  extent 
general  paralysis;  but  it  is  very  generally  conceded  that  true  gen- 
eral paresis  is  not  a  syphilitic  disorder.  Syphilis,  however,  seems 
to  predispose  to  it,  just  as  it  does  to  locomotor  ataxia. 

Hereditary  SyphiUs. — Inherited  syphilis  will  lead  to  anatomical 
changes  and  clinical  manifestations  resembling  in  all  respects  those 
of  acquired  syphilis.  Inherited  syphilis,  in  other  words,  may  pro- 
duce headaches,  cranial-nerve  palsies,  hemiplegia,  epilepsy,  mental 
disorders,  and  paraplegia.  The  disease  probably  is  the  cause  of  a 
considerable  proportion  of  the  cases  of  chronic  hydrocephalus  and  of 
many  of  the  cases  of  so-called  tuberculous  meningitis.  The  peculi- 
arities of  hereditary  syphilis  show  themselves  rather  more  in  diffuse 
symptoms  such  as  would  be  attributed  to  a  meningitis  of  the  con- 
vexhvy;  in  other  words,  convulsions  and  mental  weakness  are  rather 
more  frequent,  while  hemiplegia  and  cranial-nerve  palsies  are  com- 
paratively rare.  Hereditary  syphilis  also  very  rarely  indeed  attacks 
the  spinal  cord,  although  it  is  not  unlikely  that  it  is  a  factor  in  the 
production  of  some  of  the  hereditary  diseases  of  that  organ.  He- 
reditary syphilis  develops  at  any  time  from  birth  to  the  eighteenth 
year,  but  most  commonly  under  the  age  of  five  years. 

Pathology. — I  have  already  given  some  indications  of  the  patho- 
logical changes  produced  by  syphilis.  The  disease  affects  the  ner- 
vous system  (1)  by  producing  a  meningitis  with  infiltration,  (2)  by 
producing  gummatous  masses,  (3)  by  producing  an  inflammation  of 
the  arteries,  and  (4)  by  so  influencing  the  nervous  system  as  to  lead 
to  the  development  of  degenerative  diseases.  Of  all  these  forms  of 
anatomical  change  it  is  the  arteries  that  are  most  often  affected,  and 
particularly  the  arteries  at  the  base  of  the  brain. 

Syphilitic  meningitis  is  characterized  by  the  proliferation  of 
round  cells  and  the  preponderance  of  an  exudate  which  has  a  ten- 


TUMORS   OF   THE    BRAIN — SYPHILIS.  465 

dency  to  infiltrate  into  the  nervous  tissues.  The  anatomical  char- 
acteristics of  the  syphilitic  gumma  must  be  studied  in  special  text- 
books. The  inflammation  of  the  arteries  attacks  first  the  external 
coat  and  adventitia,  producing  there  an  enormous  multiplication  of 
round  cells.  The  external  coat  becomes  weakened,  and  as  a  result 
there  develops  beneath  it,  between  the  intima  and  the  elastic  layer, 
another  exudate  which  constitutes  what  is  known  as  endarteritis. 
In  syphilitic  arteritis,  therefore,  there  is  both  a  peri-arteritis  and  an 
endarteritis;  the  former  being  usually  the  primary  and  most  essen- 
tial process.  The  endarteritis,  however,  as  it  develops  gradually 
produces  an  occlusion  of  the  arteries.  This  cuts  off  the  circulation 
of  the  blood  and  leads  to  softening  of  the  part.  There  is  also  a 
development  of  a  hyaline  degeneration  in  the  arteries,  which  some 
regard  as  a  very  essential  part  of  the  anatomical  change. 

Diagnosis. — The  diagnosis  of  nervous  syphilis  is  based  upon  the 
history  of  an  infection,  the  irregularity  and  fugacity  of  the  symp- 
toms, the  intense  headaches,  the  presence  of  an  optic  neuritis,  the 
age  of  the  patient,  and  the  results  of  treatment.  In  estimating  the 
importance  of  the  history  of  infection,  it  should  be  remembered  that 
the  third  year  after  infection  is  the  serious  one  for  the  development 
in  particular  of  those  symptoms  produced  by  obliterating  arteritis. 
In  hereditary  syphilis  the  presence  of  the  Hutchinson  teeth,  the 
hazy  cornea,  and  deafness  or  other  ear  trouble  help  us  in  diagnosis. 
The  headache  of  syphilis  is  rather  characteristic.  It  may  attack 
any  part  of  the  head,  but  is  usually  unilateral  or  irregular,  or  again 
it  may  be  bilateral  in  its  distribution.  The  pain  is  very  intense  and 
sometimes  exhibits  a  certain  periodicity.  It  is  usually  worse  at 
night.  It  is  apt  to  last  continuously  for  from  five  days  to  three  or 
four  weeks.  Headache  of  this  character,  followed  by  the  paralysis 
of  one  or  more  cranial  nerves  or  by  an  attack  of  hemiplegia,  is  ex- 
iy  suggestive  of  syphilis.  Optic  neuritis  is  very  liable  to  occur 
when  the  disease  shows  other  evidences  of  being  situated  at  the  base 
of  the  brain.  This  optic  neuritis  is  associated  with  contraction  of 
the  visual  field,  and  a  characteristic  feature  of  this  contraction  is 
that  it  varies  a  great  deal  from  week  to  week.  The  sex  and  age  of 
the  patient  may  be  taken  into  consideration  in  weighing  the  evidence, 
and  finally  the  prompt  effects  of  the  use  of  iodide  of  potassium  should 
have  very  decided  weight. 

Prognosis. — Tt  is  very  difficult  to  give  definite  facts  regarding 
the  prognosis  of  syphilis.  Unquestionably  the  outlook  is  much  more 
favorable  than  it  is  for  any  other  organic  disease  of  the  nervous 
system.  "When  the  syphilitic  process  has  not  produced  so  much 
arterial  disease  as  to  lead  to  obliteration  of  vessels  and  softening,  a 
30 


466  DISEASES    OF  THE    NERVOUS    SYSTEM. 

very  great  degree  of  improvement  and  even  a  recovery  may  be  ex- 
pected. So  far  as  injuries  to  the  nerves  or  nerve  roots  go,  we  can  gen- 
erally expect  a  great  improvement  or  cure.  Lesions  of  the  convex- 
ity are  usually  amenable  to  treatment.  Syphilitic  hemiplegia  has  a 
not  much  better  prognosis  than  hemiplegia  from  other  causes.  Syph- 
ilitic myelitis  has  a  not  very  good  prognosis,  but  it  is  better  than 
that  of  myelitis  due  to  trauma.  Nervous  syphilis  may  last  from 
one  to  three  or  four  years.  The  effects  of  the  disease  may,  if  nerve 
tissue  is  destroyed,  last  a  lifetime. 

Treatment. — As  regards  the  prophylaxis,  it  is  important  that 
persons  who  have  become  infected  by  syphilis  should  be  treated 
with  iodide  of  potassium  in  the  second  as  well  as  the  third  stage  of 
the  disease.  After  the  first  year  at  least,  the  patient  should  not 
neglect  to  take  a  certain  amount  of  iodide  of  potassium  four  times 
a  year,  each  course  of  treatment  lasting  six  weeks.  The  patient 
should  be  warned  against  indulging  in  alcohol,  against  all  excesses, 
mental  as  well  as  physical.  A  laborious  life  full  of  worry  and  anx- 
iety, in  which  the  patient  attempts  to  help  himself  along  with  stim- 
ulants, is  surely  provocative  of  nervous  syphilis. 

The  treatment  of  the  disease  when  it  has  appeared  consists 
mainly  in  the  administration  of  iodide  of  potasium  or  sodium.  This 
should  be  given  in  beginning  doses  of  ten  grains  three  times  a  day 
and  increased  gradually  until  the  maximum  amount  which  the  pa- 
tient can  bear  is  taken.  This  maximum  is  usually  between  three 
and  four  hundred  grains  a  day.  In  some  cases  it  is  important  to 
give  more  than  this — as  much,  that  is  to  say,  as  two  hundred  grains 
three  times  a  day,  and  it  is  the  general  experience  of  American 
neurologists  that  results  can  be  obtained  by  these  large  doses  which 
cannot  be  obtained  by  smaller  ones.  In  my  own  experience  I  have 
known  a  patient  to  take  five  hundred  grains  three  times  a  day  for  a 
considerable  time  without  harm,  and  indeed  with  benefit.  Usually, 
however,  such  extraordinary  doses  are  rarely  needed.  It  is  found 
that,  as  a  rule,  patients  tolerate  large  doses  of  iodide  quite  as  well 
as  smaller  ones,  and  sometimes  the  iodism  produced  by  small  doses 
disappears  when  large  doses  are  given.  The  drug  is  best  adminis- 
tered largely  diluted  with  water  or  with  Vichy  or  in  milk,  and  taken 
after  meals.  Some  persons  bear  it  better  before  meals.  It  is  oc- 
casionally advisable  to  combine  mercury  with  the  iodide.  This  may 
be  given  in  the  form  of  the  bichloride  or  by  an  inunction.  Other 
drugs  which  are  of  value  are  the  ordinary  tonics,  such  as  iron, 
quinine,  and  the  bitters  and  mineral  acids.  Plenty  of  good  food, 
out-door  air,  and  all  those  things  which  will  improve  the  general 
health  of  the  patient  are  indicated. 


CHAPTER  XXL 

GENEKAL  PARESIS:  GENERAL  PARALYSIS  OF  THE 
INSANE— DEMENTIA  PARALYTICA. 

General  paresis  is  a  progressive  disease  of  the  brain  running  a 
course  of  about  three  years,  characterized  by  abnormal  mental  symp- 
toms, ending  in  dementia,  associated  with  physical  weakness  and 
certain  characteristic  physical  symptoms. 

Etiology. — Paresis,  as  it  is  usually  termed,  is  a  disease  of  mod- 
ern civilization,  and,  as  Krafft-Ebing  states  it,  of  syphilization. 
It  was  a  medical  curiosity  a  hundred  years  ago ;  now,  it  is  extremely 
frequent  in  our  asylums,  in  neurological  clinics,  and  in  private  prac- 
tice. It  has  become  much  more  common  of  late  years  in  this  coun- 
try. It  is  found  in  nearly  all  the  civilized  races  of  Europe  and 
America,  but  is  rare  in  Africa  and  Asia.  It  affects  even  the  in- 
ferior races  living  among  civilized  people,  and  is  found,  for  ex- 
ample, among  the  negroes  of  the  United  States. 

It  is  not  a  disease  which  is  directly  inherited,  but  the  neuro- 
pathic constitution  predisposes  to  it,  and  occasional  cases  are  seen 
m  early  life  which  may  be  said  to  be  of  congenital  origin  and  are 
due  to  syphilis  or  degeneration  hi  the  parent.  It  occurs  much  more 
often  in  men  than  in  women,  the  proportion  being  about  5  to  1. 
The  proportion  of  women  is  slowly  becoming  greater.  In  private 
practice  among  the  better  class  the  number  of  women  who  have  the 
disease  is  very  small.  In  my  own  case  the  number  of  paretic  women 
is  about  six  per  cent  in  one  hundred  cases.* 

The  excessive  use  of  alcohol  is  a  predisposing  cause,  as  is  also 
excessive  mental  exertion,  particularly  if  combined  with  emotional 
strain  and  excitement.  Sexual  excesses  and  abuse  are  also  predis- 
posing causes,  but  the  common  view,  that  the  disease  is  the  result 
of  perverted  sexual  indulgence,  is  not  correct.  Syphilis  is,  no 
doubt,  the  most  essential  of  all  the  predisposing  causes,  and  paresis 
must  be  put  down,  with  tabes  dorsalis,  as  one  of  the  parasyphilitic 

*  Among  50  private  cases  there  were  IT  men  and  :!  women  (1  t<>  16).  There 
was  a  distinct  history  of  syphilis  in  28  (nearly  fifty  per  cent).  The  national- 
ities were:  United  States,  27;  Hebrews;  10;  Irish,  9:  Germans,  3;  Italians,  1. 
Total,  50. 


468  DISEASES    OF    THE    NERVOUS    SYSTEM. 

diseases,  or,  as  I  prefer  to  call  it,  one  of  the  degenerative  forms  of 
syphilis. 

Statistics  do  not  yet  give  more  than  twenty  to  fifty  per  cent  of 
cases  with  undoubted  histories  of  syphilis ;  *  in  my  own  experience 
this  percentage  is  fifty,  and  the  disease  is  su  often  and  so  distinctly 
traced  to  syphilis  in  a  large  number  of  cases  that  we  must  infer  its 
relationship  in  the  rest.  Injuries,  sunstroke,  exposure,  acute  dis- 
eases may  be  put  down  as  exciting  causes,  but  their  importance  is 
not  very  great.  An  almost  sure  recipe  for  producing  a  case  of 
paresis  is  this:  Let  a  man  of  nervous  constitution  acquire  syphilis 
between  the  ages  of  twenty  and  thirty,  then  let  him  work  as  hard 
as  possible  without  vacation  under  great  mental  strain,  drink  a  great 
deal  of  alcohol,  and  indulge  excessively  sexually.  This  will  be 
pretty  sure  to  bring  on  paresis  in  ten  or  fifteen  years. 

The  disease  occurs  most  often  between  the  ages  of  twenty  and 
forty,  but  it  is  seen  both  earlier  and  later  than  these  ages.  It  oc- 
curs oftener  in  married  men  and  women.  It  is  seen  oftener  in  the 
city  than  in  the  country. 

Symptoms. — In  its  typical  manifestation  the  disease  shows  two 
stages  :  one  of  excitement  or  irritation  ;  the  second  of  dementia  and 
paralysis.  In  place  of  the  excitement  of  the  first  stage  the  patient 
may  have  a  prolonged  period  of  hypochondriasis  or  melancholia,  or, 
with  no  preliminary  stage  of  excitement  or  depression,  may  pass 
gradually  into  dementia,  the  mental  and  bodily  feebleness  going 
on  together. 

The  first  type  is  the  most  common  of  all,  although  the  opinion 
is  growing  that  the  types  characterized  by  little  active  mental  dis- 
turbance and  by  more  marked  physical  symptoms  are  becoming  more 
frequent;  in  other  words,  that  paresis  is  becoming  more  a  disease 
of  the  brain  and  spinal  cord  proper  and  less  a  disease  of  the  mind, 
the  mental  symptoms  t  being  almost  from  the  first  more  of  a  pro- 
gressive dementia. 

Excited  Type.  —  In  the  first  type  of  cases  the  patient  begins  by 
Bhowing  unusual  irritability  of  temper ;  trivial  things  annoy  him,  and 
his  had  humor  and  change  of  disposition  become  noticeable  in  his 
family  relations  and  in  his  business.     He  is  fretful ;  complains  of 

*Among  personal  cases  Regis  found  eighty  percent  syphilitic.  Krafft- 
Ebing  found,  among  17-">,  fifty-six  per  cent  gave  a  history  of  syphilis.  In  4t 
cases  of  paresis  in  children  syphilis  could  be  traced  in  87.8  per  cent  (Zappert). 
Among  2i  cases  in  adults.  16  g%ve  a  history  of  syphilis  (F.  Mott). 

t  Among  40  private  cases  the  types  were:  excited.  15;  hypochondriacal, 
10;  dementing,  15.  Mendel,  among  194  cases  of  all  kinds  observed  since  1880, 
found  37  of  the  typical  form  and  70  of  the  dementing  type. 


GENERAL    PAEESIS.  469 

being  easily  fatigued;  loses  interest  in  his  affairs,  and  is  unable 
to  fix  his  attention  for  any  length  of  time  upon  them.  He  makes 
occasional  mistakes  of  judgment,  and  does  some  extravagant  or  fool- 
ish thing  in  the  way  of  purchasing  or  selling.  This  condition  of 
irritability  is  followed  by  one  of  great  mental  exaltation.  The 
patient  becomes  very  happy  and  cheerful  and  confident;  he  feels 
better  than  he  ever  did  before  in  his  life.  He  talks  excessively, 
and  is  effusive  and  jocose  when  he  used  to  be  sober  and  reserved.  He 
develops  great  schemes  for  the  future,  he  lavishes  money  uselessly 
in  making  presents  to  his  family  and  friends,  or  in  some  extra- 
ordinary business  venture,  and  imagines  himself  possessed  of  im- 
mense wealth  or  great  power.  He  has  what  are  called  delusions  of 
grandeur,  or  megalomania.  This  condition  of  exaltation  is  inter- 
rupted by  outbursts  of  violence,  especially  if  it  leads  him  to  indulge 
in  drink,  as  is  often  the  ease.  In  the  course  of  three  or  four  months 
the  symptoms  become  so  marked  that  the  family  recognize  the  seri- 
ousness of  his  state,  and  he  is  confined  in  some  institution  where  he 
can  do  himself  and  others  no  harm.  Under  institutional  regime  he 
now  becomes  somewhat  more  quiet;  his  exaltation  softens  down. 
His  symptoms  may  even  remit,  and  for  a  time  he  becomes  nearly 
or  quite  rational.  But  after  some  months  lie  begins  to  show  dis- 
tinct signs  of  dementia;  the  memory  becomes  weak,  he  forgets  re- 
cent events,  mislays  things,  makes  mistakes  in  his  accounts,  is  un- 
able to  add  correctly";  he  cannot  write  a  letter  coherently,  or  if  he 
does  there  are  mistakes  in  spelling  and  elisions  of  letters. 

During  the  period  of  exaltation  there  gradually  appear  physical 
symptoms  which  are  very  characteristic.  The  patient's  hands  be- 
come tremulous,  and  his  handwriting  is  so  affected  that  his  signa- 
ture often  cannot  be  recognised.  There  is  distinct  and  decided 
facial  tremor,  particularly  apparent  if  the  patient  is  made  to  (dose 
the  eyes  and  stretch  the  muscles  of  the  lips  so  as  to  show  the  teeth. 

There  is  marked  tremor  of  the  tongue,  all  this  tremulousness 
being  much  more  exaggerated  than  is  seen  in  other  diseases,  except 
occasionally  hi  acute  alcoholism.  The  speech  becomes  stuttering 
and  thick,  and  he  cannot  pronounce  long  words  (dearly.  On  exam- 
ination of  the  reflexes  it  is  usually  found  that  the  knee-jerks  are 
exaggerated.  The  pupils  are  almost  always  uneven,  and,  as  a  rule, 
react  badlj  t<>  light  though  fairly  well  to  accommodation,  showing, 
ill  other  words,  the  Argvll-Roliertson  pupil;  sometimes  they  do  not 
reaci  either  to  light  or  accommodation.     The  fundus  ocnli  is  normal. 

There  is  an  early  and  decided  weakness  of  the  sexual  function. 
'Idie  bladder  may  also  become  Aveak.  The  appetite  and  vegetative 
organs  remain  in  fairly  good  condition.     The  patient  often  suffers 


470  DISEASES    OF   THE    NERVOUS   SYSTEM. 

from  persistent  insomnia.  During  this  time  he  also  has  occa- 
sionally vertiginous,  syncopal,  or  apoplectiform  attacks.  In  the 
latter  he  falls  clown  and  perhaps  has  hemiplegia  lasting  for  a  few- 
days  or  a  few  weeks.     An  epileptic  convulsion  may  occur. 

In  some  cases  the  knee-jerks  are  abolished,  and  there  are  some 
ataxia  and  evidence  of  a  posterior  sclerosis.  The  general  muscular 
power  is  much  diminished,  and  the  patient  is  unable  to  take  long 
walks  or  do  any  great  amount  of  physical  exercise. 

In  the  second  stage  the  most  striking  feature  is  the  gradual 
onset  of  dementia.  The  patient  now  becomes  more  quiet  and  is 
inclined  to  sleep  during  the  daytime.  He  takes  little  interest  in 
affairs  about  him,  is  extremely  forgetful,  and  is  often  unable  to  rec- 
ognize even  his  intimate  friends.  He  no  longer  knows  the  day  of 
the  month  nor  the  year,  and  cannot  tell  one  anything  about  current 
events  of  the  day.  He  becomes  gradually  careless  about  his  per- 
son, and  has  to  be  watched  while  at  his  meals  lest  he  spill  food  on 
his  clothes,  and  at  the  toilet  lest  he  soil  himself.  Finally,  he  needs 
to  be  cared  for  as  if  he  were  a  child. 

At  this  late  period  again,  attacks  of  an  apoplectiform  character 
may  come  on,  leaving  him  temporarily  or  perhaps  permanently  hemi- 
plegic.  His  appetite  often  continues  good,  sometimes  voracious, 
and  he  may  gain  flesh.  He  is  apt  at  this  time  to  have  periods  of 
excitement  at  which  he  has  delusions  of  persecution,  or  he  may  have 
some  slight  delusions  of  grandeur.  One  patient  of  mine  used  to 
weigh  himself  every  day  and  think  he  was  gaining  ten  pounds  each 
time.     He  kept  on  till  he  thought  he  weighed  nine  hundred  pounds. 

In  the  last  scene  of  all  he  becomes  bedridden  and  helpless,  and 
finally  dies  of  exhaustion.  The  somatic  symptoms  during  this  last 
period  consist  of  increased  tremor,  disturbances  of  speech,  and  grad- 
ual muscular  weakness  until  the  patient  becomes  helpless. 

The  average  duration  of  the  disease  is  about  three  years.  There 
are  some  acute,  galloping  forms  in  which  the  patient  dies  within  a 
year,  and  there  are  some  cases  in  which  the  patient  reaches  a  stage 
of  partial  or  complete  dementia  and  remains  in  this  condition  for 
ten  or  fifteen  years. 

The  Hypochondriacal  Type. — In  this  form  the  disease  begins  with 
symptoms  resembling  those  of  neurasthenia  and  hypochondriasis. 
The  patient  complains  of  disagreeable  sensations  about  his  head, 
hemicrania,  pain  in  his  limbs  and  back,  inability  to  sleep,  disorders 
of  the  stomach,  and  vague  sensations  of  discomfort  and  oppression 
which  he  is  unable  distinctly  to  describe.  These  patients  are  often 
treated  as  neurasthenics  for  a  long  time,  and  at  first  show  hardly 
any  physical  or  mental  symptoms  suggestive  of  the  real  trouble. 


GENERAL   PARESIS.  471 

Careful  examination,  however,  almost  invariably  reveals  rigid  pupils, 
or  a  history  of  syphilis  which  should  always  put  one  on  guard. 

After  a  period  of  perhaps  a  year,  evidences  of  mental  disturb- 
ances begin  to  appear,  and  they  are  mostly  those  of  dementia  with 
perhaps  delusions  of  persecutions  and  suspicion.  These  delusions 
may  be  accompanied  by  occasional  outbreaks  of  excitement  aud  vio- 
lence, but  the  paretic  is  rarely  homicidal,  and,  it  may  be  added, 
rarely  suicidal.  After  dementia  has  set  in  the  physical  symptoms 
of  tremor,  scanning  speech,  and  tremulous  handwriting  all  become 
noticeable,  and  the  final  stage  resembles  that  of  the  other  form. 

Dementing  Type. — In  a  third  type  there  is  a  primary  dementia. 
The  disease  begins  without  any  excitement  or  any  special  depression, 
with  symptoms  of  forgetfulness,  lack  of  attention  to  business,  and 
incapacity  to  do  work.  The  patient  makes  mistakes  in  his  calcula- 
tions, mislays  and  forgets  things,  and  soon  is  found  by  his  employer 
to  be  of  no  use.  He  is  often  good-natured,  not  unhappy,  and  with- 
out distinct  delusions  of  any  kind.  The  somatic  symptoms  of 
tremor,  fixed  pupils,  and  exaggerated  reflexes  appear  and  become 
hnally  characteristic.  Scanning  speech  is  not  always  present,  or 
comes  on  later.* 

Syphilitic  Pseudo-Paresis. — There  are  some  cases  of  paresis  in 
which  symptoms  of  exudative  syphilis  introduce  the  disease.  The 
patient  has  at  first  eye  palsies  or  attacks  of  hemiplegia  with  intense 
headache  followed  by  convulsions.  It  is  recognized  that  he  has  a 
syphilitic  exudate  pressing  upon  some  part  of  the  brain,  either  the 
base  or  the  convexity,  usually  the  former.  Under  proper  treatment 
this  resolves  and  he  gets  over  the  paralysis  and  the  seizures,  but  it 
is  now  found  that  his  mind  is  slightly  affected.  He  has  no  delu- 
sions perhaps,  and  no  immediate  exaltation,  but  his  memory  is  im- 
paired, judgment  weakened,  his  emotional  condition  is  one  of  ex- 
citability, and  he  has  to  give  up  business  and  live  a  quiet,  inactive 
life.  If  he  docs  this,  in  some  cases  the  disease  becomes  arrested, 
and  he  remains  fairly  well  for  a  number  of  years.  Cases  of  appar- 
ent recovery  even  have  been  reported,  but  in  my  experience  demen- 
tia finally  sets  in,  though  it  may  not  be  till  six  or  sown  years  have 
passed. 

Alcoholic  Pseudo-Paresis.  -Persons  who  have  for  long  periods  of 
time  continuously  and  excessively  indulged  in  alcohol  may  develop, 

*Tlic  urine  in  the  excitable  siaLredio\vsahnormal  increase  of  Bolids;  in  the 
quiet  ami  dementing  Btage  abnormal  diminution  i  Laillier).  The  red  blood  cells 
and  haemoglobin  fall  below  the  normal,  the  latter  more  than  the  former;  most 
cases  show  a  slight  leueocytosis.  There  is  a  decrease  in  the  Lymphocytes  and. 
increase  of  large  mononuclear  cells  (J.  A.  Capps). 


472  DISEASES    OF    THE    NERVOUS    SYSTEM. 

and  generally  do,  a  condition  of  mental  weakness  which  to  a  certain 
extent  simulates  paresis.  If  these  patients  have  not  had  syphilis, 
however,  it  is  not  a  true  paresis.  The  patients  become  weak- 
minded,  feeble  in  judgment,  poor  in  memory,  their  moral  instincts 
get  out  of  control,  and  acts  of  extraordinary  selfishness,  bestiality, 
and  besottedness  are  manifest.  They  gradually  become  more  de- 
mented, and  finally  enter  a  condition  of  dementia  if  they  are  not 
carried  off  by  some  intercurrent  disease,  as  is  often  the  case.  These 
cases,  however,  do  not  present  the  physical  symptoms  of  paresis. 
They  do  not  have  the  speech  disturbances,  the  paralyses,  or  the 
apoplectiform  seizures  that  characterize  the  true  disease,  and  if  they 
can  be  kept  from  alcohol  they  may  remain  in  a  state  of  partial  de- 
mentia for  many  years. 

Pathology.  — The  disease,  as  I  have  already  stated,  is  essentially 
a  parasyphilitic  one,  and  is  due  to  a  degenerative  change  which  sets 
in  in  the  cells  of  the  brain  as  the  result  of  poisoning  by  syphilis. 
These  syphilitic  changes  produce  thickening  of  the  membranes  and 
arteries  of  the  brain,  with  proliferation  of  the  perivascular  tissue. 
It  is  believed  by  some  that  the  vascular  changes  precede  the  cell  de- 
generation. It  is,  however,  a  more  general  opinion  that  the  cell 
degeneration  is  primary,  just  as  it  is  in  locomotor  ataxia. 

Examination  of  the  brain  of  the  paretic  shows  that  the  dura 
mater  is  thickened  and  vascular,  and  the  membrane  is  adherent  to 
the  cranial  bones.  The  brain  itself  has  undergone  atrophy  (two  to 
six  ounces),  and  there  is  increase  of  the  cerebro-spinal  fluid.  The 
pia  mater,  especially  in  the  fore  and  mid  regions  of  the  brain,  is 
congested,  and  there  is  thickening  of  it  and  of  the  arachnoid,  and 
the  whole  membrane  is  adherent  to  the  cortex  beneath  it,  which 
is  found  to  be  oedematous. 

Microscopical  examination  shows  increase  of  connective  tissue 
around  the  blood-vessels  of  the  cortex,  thickening  of  the  vascular 
coats,  and  degeneration  of  the  nerve  cells  in  all  grades.  The  dis- 
ease involves  not  only  the  gray  cortex  but  the  cells  and  nuclei  of 
the  medulla.  There  are  of  ten  associated  with  paresis  lesions  of  the 
posterior  and  lateral  columns  of  the  cord ;  in  fact,  it  is  not  very  un- 
common to  have  a  certain  amount  of  locomotor  ataxia  associated 
with  the  lesions  of  paresis.  A  small  percentage  (three  to  five)  of 
the  cases  of  locomotor  ataxia  end  in  this  disease. 

Prognosis. — The  prognosis  is  usually  said  to  be  invariably  bad. 
If  one  sees  the  patient,  however,  in  the  very  earliest  stage  and  re- 
moves him  at  once  from  all  forms  of  excitement,  and  makes  him 
live  quietly  for  a  year,  using  anti-luetic  or  tonic  treatment,  one  can 
sometimes  cheek  the  disease,  at  least  for  a  time.     1  have  several 


GENERAL   PARESIS.  473 

patients  who  seem  in  this  way  to  have  been  apparently  cured.  When 
the  disease  has  well  entered  upon  its  course  it  is  incurable  by  any 
ineasures  as  yet  known.  It  is  probably  true  that  the  disease  shows 
remissions  oftener  than  it  used  to  do,  and  that  it  is  less  refractory 
to  treatment  than  it  was  formerly. 

Treatment. — As  some  of  the  early  symptoms  of  the  disease  are 
often  associated  with  a  history  of  syphilitic  infection,  it  is  wise  to 
put  the  patient  promptly  under  anti-syphilitic  treatment.  At  the 
same  time  he  should  be  sent  to  some  quiet  place  in  the  country  or 
to  some  institution  where  he  can  be  made  to  lead  an  extremely  reg- 
ular and  cpiiet,  even  life.  These  two  measures,  if  applied  early, 
have  produced  remissions  which  have  lasted  for  from  three  to  six 
months,  even  a  year.  After  the  anti-syphilitic  treatment  the  pa- 
tient should  be  given  various  tonic  measures,  such  as  the  glycero- 
phosphate of  lime  in  doses  of  thirty  grains  a  day,  with  iron  and 
strychnine. 

The  use  of  a  cold  wet  pack  and  ice  cap  applied  daily  for  a 
period  of  about  one  to  two  hours,  followed  by  massage,  sometimes 
produces  decided  relief,  especially  in  the  more  excitable  cases.  The 
tonic  form  of  hydrotherapy,  such  as  cold  baths  and  douches,  is 
indicated  in  the  depressed  types. 


CHAPTER   XXII. 

FUNCTIONAL  NERVOUS   DISEASES. 

Functional  nervous  diseases  are  those  in  which  no  definite 
known  anatomical  change  underlies  the  morbid  phenomena.  On 
this  account  it  is  customary  to  classify  them  on  a  clinical  basis.  We 
can,  however,  also  make  etiological  and  pathogenic  subdivisions. 
Applying  such  a  method  now,  we  have  two  broadly  distinguished 
classes:  the  primary,  or  degenerative,  and  the  secondary,  or  ac- 
quired neuroses.  Such  a  classification  is  suggestive  and  helpful, 
though  not  perfectly  correct,  because  several  factors  often  enter  into 
the  cause  of  the  same  neurosis. 


Acquired 
neuroses. 


Primary  neurasthenia,  hypochondriasis 

Epilepsy. 

Hysteria  major. 

Hereditary  chorea. 

General  spasmodic  tics. 

Myotonia. 

Chorea. 

Tetanus. 

Tetany. 

Rabies. 

Tremor. 

Neuralgia. 
C  Neurasthenia. 
.   Exhaustion    andj  Hysteria 


Primary  degenerative 
neuroses. 


'From  infectious,  au- 
tochthonous,   and< 
mineral  poisons. 


]  Exophthalmic  goitre. 
I  Occupation  neuroses. 
(  Tic  douloureux. 
<  Local  spasmodic  tics. 
Paralysis  agitans. 
(^  Miscellaneous.  Vasomotor,  trophic,  and  sleep  disorders. 


shock  neuroses. 

Acquired 
tive  neuroses. 


THE  DEGENERATIVE  NEUROSES. 

Epilepsy. 

Idiopathic  epilepsy  is  a  chronic  functional  disorder  character- 
ized by  periodical  seizures  attended  by  loss  of  consciousness  and 
usually  by  convulsions.  Mental  disturbances  may  accompany  or 
take  the  place  of  the  convulsions. 


FUNCTIONAL    NERVOUS    DISEASES.  475 

Symptomatic  epilepsy  is  a  form  in  which  the  periodic  convulsive 
attacks  are  due  to  gross  organic  changes  in  the  brain. 

Jacksonian  or  partial  epilepsy  is  a  form  of  symptomatic  epilepsj7 
usually,  and  is  characterized  by  periodic  convulsions  affecting  only 
certain  groups  of  muscles,  and  often  unattended  by  loss  of  con- 
sciousness. 

Hystero-epilepsy  is  not  epilepsy,  but  a  form  of  hysteria. 

Eclampsia  or  acute  epilepsy  is  the  name  given  to  a  single  iso- 
lated attack  of  convulsions.  It  is  generally  of  the  symptomatic 
type. 

Idiopathic  epilepsy  shows  itself  in  three  rather  distinct  types 
of  attacks,  viz.  :  that  of  severe  attacks,  called  the  grand  mal;  that 
of  minor  attacks,  the  petit  mal;  and  the  rarer  larvated  forms  char- 
acterized by  acute  mental  disorder  and  called  psychical  epilepsy  or 
the  psychical  epileptic  equivalent. 

Etiology. — Predisposing  causes:  Heredity  is  the  most  potent  of 
any  single  influence.  A  history  of  epilepsy  or  insanity  is  found  in 
the  family  in  about  one-third  of  the  cases  and  rather  more  on  the 
paternal  side.  Alcoholism  and  the  intermarriage  of  neurotic  per- 
sons contribute  powerfully  to  produce  the  convulsive  tendency  in 
children.  Powerful  emotions  during  pregnancy,  accouchement  in- 
juries, and  syphilis  have  some  influence.  More  cases  occur  in  the 
country  than  the  city,  more  in  temperate  climates,  and  more  among 
in-bred  races.  All  American  statistics  (Putzel,  Hamilton,  Ham- 
mond, Starr,  and  myself)  show  a  slight  preponderance  among  males. 
European  observers  find  it  the  other  way. 

Age. — The  epileptic  age  is  between  ten  and  twenty,  and  still 
more  definitely  between  ten  and  fifteen.  In  three-fourths  of  the 
cases  the  disease  begins  before  the  age  of  twenty ;  in  one-sixth  of 
my  cases  before  the  age  of  five.  After  twenty  the  danger  of  epi- 
lepsy is  slight,  and  when  it  occurs  it  is  usually  due  to  accidental 
causes,  like  syphilis,  alcoholism,  or  plumbism.  Idiopathic  epilepsy, 
however,  may  develop  even  after  sixty.  The  accompanying  table 
shows  graphically  the  relation  of  age  to  the  development  of  epi- 
lepsy, chorea,  and  neuralgias. 

Exciting  Causes. — Exciting  causes  are  not  present  in  the  majority 
of  cases.  The  most  important  are  the  occurrence  of  rickets  at  the  time 
of  dentition,  fright,  injury  to  the  head,  sunstroke,  infectious  diseases, 
especially  scarlatina,  masturbation,  alcoholism,  and  syphilis.  Mas- 
turbation is  a  real  but  rare  cause,  so  also  is  syphilis.  The  so-called 
reflex  causes  are  ocular  and  auditory  irritations,  worms,  dyspeptic 
states,  dental  irritations,  lesions  involving  peripheral  nerves.  Some 
American  observers  put  much  stress  on  the  importance  of  ocular  ir- 


476 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


ritations.  European  writers  have  ]aid  more  emphasis  on  disease  of 
the  ear.  Probably  the  gastro-intestinal  tract  and  genital  organs  fur- 
nish the  most  important  exciting  irritations.  True  idiopathic  epi- 
lepsy" may  be  brought  out  by  peripheral  irritations ;  more  rarely  there 
occurs  only  a  reflex  epileptiform  neurosis. 

Symptoms  of  the  Convulsion. — The  patient  often  feels  some  pre- 
monitory symptoms  for  a  few  hours  or  a  clay,  consisting  of  general 
malaise,  irritability,  or  giddiness.     The  attack  begins  in  about  half 


Percentage 

of 

total  cases 

Q0% 
50% 
40  X 
30% 
20  X 
10% 

up  to 
end  of 
5thyear 

6  th 

to 
7l.h 

11* 

to 
I5*.h 

l6T-h 

t0H. 

21s-' 

to 

30* 

3!* 

to 

40* 

41s.1 
50* 

51s.4 
to 

60* 

6ls.f 
to 
70* 

r '" 

_--* 

f 

\ 

\      // 

\ 

!/ 

\ 

\ 

Fig.  217.— Table  showing  Percentage  of  Cases  op  Epilepsy,  Chorea,  and  Neu- 
ralgia Occurring  at  Each  Half-Decade  and  (after  Twenty)  Each  Decade.  Double 
Hue,  epilepsy;  dotted  line,  chorea;  single  line,  neuralgia. 

the  cases  with  a  peculiar  sensation  called  the  aura.  Often  also  a 
loud  cry  is  uttered  and  the  patient  falls  unconscious  to  the  ground. 
The  face  is  pale,  the  eyes  are  open  and  turned  up  and  to  one  side, 
and  the  pupils  dilated.  The  head  is  drawn  back  or  to  one  side,  and 
the  whole  body  is  in  a  state  of  rigidity  or  tonic  spasm.  The  arms 
are  slightly  drawn  out  from  the  trunk,  the  forearms  and  wrists 
flexed,  the  fingers  clinched  or  flexed  in  other  ways,  the  legs  and 
feet  extended.  This  tonic  stage  lasts  for  fifteen  or  twenty  seconds; 
the  face  becomes  congested  and  then  livid  from  compression  of  the 
veins  of  the  neck  and  stoppage  of  respiration.  Gradually  jerky 
movements  of  the  face  and  limbs  begin  and  the  stage  of  clonic 
spasm  sets  in.     The  trunk  and  limbs  are  now  alternately  flexed  and 


FUNCTIONAL    NERVOUS    DISEASES.  477 

extended  with  violent  shock-like  contractions,  the  facial  and  eye 
muscles  twitch,  saliva  collects  in  the  mouth,  and  as  the  tongue  is 
often  bitten  it  becomes  stained  with  blood.  The  movements  are 
sometimes  so  violent  that  the  patient  is  thrown  about  the  bed  or 
floor,  and  occasionally  a  limb  is  dislocated,  usually  the  shoulder. 
The  urine  often,  and  the  faeces  occasionally,  are  passed.  The  tem- 
perature is  raised  ±°  or  1°  F.,  rarely  more.  The  pulse,  feeble  at 
first,  becomes  frequent  and  tense,  and  then,  as  the  attack  subsides, 
becomes  feeble  again.  The  clonic  spasm  lasts  from  one-half  to  one 
or  two  minutes.  It  subsides  gradually,  and  the  patient  sinks  into  a 
stupor,  from  which  he  can  be  roused  with  difficulty.  This  stupor 
is  succeeded  by  a  heavy  sleep  of  several  hours  and  a  feeling  of  hebe- 
tude which  lasts  all  day.  Vomiting  sometimes  occurs  as  a  terminal 
symptom.  Immediately  after  the  attack  there  is  a  temporary  ex- 
haustive paralysis,  with  loss  of  knee  jerk.  The  pupils  contract 
again  and  often  oscillate.  There  may  be  a  slight  amount  of  tran- 
sient albuminuria  or  glycosuria.  The  earthy  phosphates  are  found 
increased;  urea  is  not.  There  is  a  distinct  lessening  of  haemoglobin 
in  the  blood  (Fere)  and  of  luematoblasts.  Sometimes  the  attack  is 
followed  by  others,  and  for  hours  the  patient  passes  from  one  con- 
vulsion into  another.  This  condition  is  called  status  epilepticus. 
It  usually  lasts  less  than  twelve  hours,  but  may  last  for  one  or 
more  days  and  until  finally  death  occurs  from  exhaustion.  It  de- 
velops only  in  the  severer  types. 

Symptoms  of  the  Minor  Attacks. — In  the  minor  attacks  (petit 
mat)  the  patient  suddenly  stops  in  anything  in  which  he  is  en- 
gaged, the  features  become  fixed,  the  eyes  open,  the  face  is  pale, 
the  pupils  are  dilated,  often  slight  twitching  of  the  facial  muscles  or 
of  the  limbs  occurs,  and  consciousness  is  lost.  In  a  few  seconds 
the  attack  is  over,  and  the  patient,  who  does  not  fall,  resumes  his 
work  or  conversation,  being  unconscious  of  what  lias  occurred,  ex- 
cept that  he  has  had  a  "  spell."  Often  there  is  a  warning  sensation 
or  aura.  This  is  felt  as  giddiness,  sense  of  fear,  numb  sensations 
of  the  extremities,  Hashes  of  light  or  blindness,  or  choking  sensa- 
tions. There  may  be  a  cry  uttered.  The  minor  attacks  are  in 
rarer  cases  accompanied  by  sudden  forced  movements;  the  patient 
runs  a  few  steps,  or  turns  round,  or  makes  some  automatic  movements. 
This  is  called  procursive  epilepsy. 

Symptoms  of  the  Psychical  Attacks,  —  Sometimes  the  minor  at- 
tacks are  followed  by  outbursts  of  maniacal  excitement,  or  by  sud- 
den violent  automatic  movements,  and  in  these  states  the  patient 
may  commit  crimes  of  violence.  Tu  rare  cases  the  patient  passes 
into  a  somnambulic  state,  during  which   he  performs  accustomed 


478  DISEASES    OF   THE    NERVOUS   SYSTEM. 

acts,  such  as  driving  and  walking,  automatically  and  naturally 
(somnambulic  epilepsy).  This  form  of  epilepsy  may  come  on  with- 
out a  preliminary  minor  attack,  and  then  it  is  to  be  considered  a 
"  psychical  epileptic  equivalent. " 

Minor  attacks  may  end  in  convulsions  of  a  co-ordinate  type  in 
which  the  patient  jumps,  kicks,  throws  the  arms  about  as  in  hys- 
terical attacks.     These  are  called  hysteroid  convulsions. 

The  seizure  may  consist  of  only  a  short  tonic  stage  and  a  few 
twitchings  of  the  limbs,  the  whole  lasting  but  a.f ew  seconds.  This 
is  called  an  abortive  attack.  Under  the  influence  of  medication, 
the  severe  seizures  are  often  reduced  to  abortive  forms. 

Jacksonian  01  partial  epilepsy  is  a  form  of  the  disease  charac- 
terized by  convulsive  attacks  affecting  only  a. single  group  of  mus- 
cles or  a  limb,  and  generally  not  accompanied  by  loss  of  conscious- 
ness. Jacksonian  epilepsy  is  always  symptomatic  of  some  focal 
lesion  affecting  the  cortical  motor  area  of  the  brain.  This  may  be 
a  tumor,  inflammation,  or  injury.  This  form  of  seizure  is  particu- 
larly significant  of  a  slowly  growing  brain  tumor  or  syphilis. 

The  aura  usually  consists  of  a  sensation  of  numbness,  prickling 
or  of  a  breeze  beginning  in  the  hand  or  leg  and  passing  up  to  the  head, 
when  consciousness  is  lost.  Still  oftener  there  is  a  peculiar  sensa- 
tion starting  in  the  epigastrium  and  passing  upward.  More  rarely 
there  are  special-sense  aura?,  such  as  flashes  of  light,  noises,  or 
voices  and  peculiar  tastes  or  smells.  Besides  these  there  occur 
feelings  of  giddiness,  dreamy  states,  peculiar  sensations  in  the 
head,  and  indescribable  general  sensations. 

The  aurse  may  be  divided  into : 

Visceral — epigastric,  laryngeal,  cardiac. 

Cutaneous  sensations. 

Special  senses — flashes  of  light,  etc. 

Psychical — emotions,  dreamy  states,  etc. 

Cephalic — giddiness,  etc. 

The  aura  is  thought  to  indicate  the  seat  of  the  first  discharge  of 
nerve  force,  and  its  study  is  of  most  importance  in  connection  with 
symptomatic  epilepsies,  as  will  be  shown  later. 

Relative  frequency  of  the  different  kinds  of  attacks.  The  severe 
attacks  are  the  most  frequent,  next  come  combinations  of  severe  and 
minor  attacks,  and  next  minor  attacks  alone,  while  the  psychical 
forms  are  the  rarest. 

Frequency  of  the,  Attacks. — The  severe  attacks  may  come  on  only 
once  or  twice  a  year,  and  this  commonly  occurs  during  the  develop- 
ment of  the  disease.  The  frequency  gradually  increases  until  they 
occur  every  month,  or  two  or  three  times  a  month.     Sometimes  the 


FUNCTIONAL    NERVOUS   DISEASES.  479 

fits  occur  in  groups  of  four  or  five  every  month,  or  two.  In  very 
bad  cases  convulsions  occur  every  day.  The  petit-mal  attacks  are 
more  frequent  and  usually  occur  daily. 

Time  of  Attacks. — The  moon  and  the  seasons  have  no  influence. 
More  attacks  occur  during  waking  hours  than  during  sleep;  but 
two-thirds  of  the  attacks  occur  between  8  a.m.  and  8  p.m.  Many 
patients  have  their  attacks  early  in  the  morning  just  after  awaken- 
ing {matutinal  epilepsy).  Many  attacks  occur  between  3  and  5 
a.m.,  when  the  temperature  of  the  body  and  the  vital  powers  are 
at  the  lowest. 

State  of  Patient  between  Attacks.- — Epileptic  patients  often  feel 
better  for  a  time  after  the  convulsion  is  over.  They  not  rarely 
suffer  from  severe  neuralgic  headaches ;  the  appetite  is  capricious, 
often  in  children  it  is  voracious,  but  in  older  cases  there  may  be 
anorexia;  the  bowels  are  usually  constipated;  the  pulse  is  small, 
soft,  and  frequent  in  the  young,  later  it  is  often  slow. 

Mental  Condition. — A  gradual  mental  deterioration  occurs  in  the 
great  majority  of  epileptics,  but  it  is  slight  in  some  and  not  very 
great  in  others.  It  shows  itself  by  feebleness  of  memory,  irrita- 
bility of  temper,  selfishness,  incapacity  to  concentrate  the  mind  or 
to  carry  out  a  purpose.  In  children  great  mischievousness  and  lack 
of  moral  sense,  with  vicious  impulses,  may  appear.  The  mental 
deterioration  is  dependent  on  those  underlying  factors  which  cause 
the  disease.  It  is  apparently  in  some  cases  due  to  the  excessive 
number  of  the  fits.  This  is  not  necessarily  the  case,  nor  it  is  gen- 
erally true  that  it  occurs  more  often  with  petit  mat.  It  is  more 
marked  in  cases  beginning  very  early  in  life,  but  this  is  true  only  when 
there  are  decided  marks  of  physical  and  mental  degeneration  pres- 
ent. A  certain  rather  small  percentage  of  epileptics  become  either 
demented  or  insane.  True  epilepsy  is  not  compatible  with  extraordi- 
nary intellectual  endowments.  Caesar,  Napoleon,  Peter  the  Great, 
and  other  geniuses  may  have  had  some  symptomatic  fits,  but  not 
idiopathic  epilepsy. 

Physical  ( 'ondition. — Epileptics  are  rather  undersized  and  of  not 
very  vol mst  constitution  (Fere).  They  always  present  some  of  the 
marks  of  degeneration,  physical,  physiological,  or  mental.  Such 
marks  or  stigmata  are  about  ten  times  more  frequent  than  in  healthy 
persons.  The  physical  stigmata  are  (Fere)  short  stature,  cranial 
asymmetry  (in  71  percent),  short  parietal  or  frontal  arc,  and  triangu- 
lar skull ;  in  women  high  prominent  forehead ;  bad  teeth  badly  placed, 
high  palatal  arch;  facial  asymmetry;  prominence  of  occiput  and 
lemurian  hypophysis ;  differences  in  color,  size,  position,  and  shape 
of  pupils;    astigmatism  (in  75  per  cent  of  cases);    badly  shaped 


480 


DISEASES    OF   THE    XEKVOL'S    SYSTEM. 


and  placed  ears ;  misplaced  crown  of  scalp ;  low  vital  capacity ;  small 
genitals,  atrophic  uterus ;  greater  development  of  left  side;  long 
fingers.  Cranial  deformities  of  pronounced  type  occur  in  epileptics 
associated  with  idiocy,  hemiplegia,  and  brain  defects  of  early  origin. 
Sometimes,  apparently  from  a  premature  ossification  of  sutures, 
there  are  the  peculiar  shapes  of  the  skull  known  as  scaphocephaly, 
or  steeple  skull,  and  plagiocephaly,  or  obliquely  deformed  skull. 

The  physiological  marks  of  deterioration  are  a  lessened  muscular 
strength  (as  35  to  50),  habit  choreas,  a  rather  imperfect  eye  with 
excessive  amount  of  astigmatism  and  functional  muscular  weakness. 
There  is  a  lessened  vital  capacity,  weak  and  slow  digestion,  and 


Fig.  218.— Diffuse  Neuroglia  Sclerosis 
of  the  Cortex  dj  Epilepsy. 


Fig.  219.— Same,  Enlarged  CChaslin). 


sexual  atrophy  or  irritability.  The  excretion  of  phosphoric  acid  is 
below  normal  as  compared  with  urea. 

The  psychical  stigmata  are  mental  feebleness,  moral  insensibility, 
irritability,  wayward  and  vicious  impulses,  lack  of  will  power,  and 
sexual  aberrations. 

Pathology. — The  body  of  the  epileptic  shows  sometimes  skin 
eruptions  and  ulcers,  the  result  of  treatment.  There  are  often  evi- 
dences of  local  injuries  and  fractures  due  to  falls.  The  organs  may 
show  vices  of  conformation.  The  uterus  is  frequently  infantile  or 
sharply  flexed.  Deformation  of  the  occipital  bone  or  the  atlas  so 
as  to  produce  narrowing  of  the  upper  spinal  canal  has  been  noticed. 
The  brain  may  be  unduly  large  or  small,  but  there  is  nothing  con- 
stant in  this,  nor  is  there  an  abnormal  difference  in  the  weight  of 
the  two  hemispheres.  The  convolutions  show  many  anomalies,  but 
there  is  in  them  nothing  specific.  On  the»whole  the  convolutional 
type  is  a  simple  one.  The  pathological  change  found  most  con- 
stantly in  epilepsy  is  an  induration  or  sclerosis  (gliosis).     This 


FUNCTIONAL    NERVOUS    DISEASES.  481 

affects  the  cornu  ammonis  rather  often  (4  to  10  per  cent),  more 
rarely  the  olivary  bodies  or  cerebellum.  Besides  this,  small  patches 
of  induration  occur  in  the  gray  matter  in  various  parts  of  the  cor- 
tex. Chaslin  finds  a  diffuse  increase  of  neuroglia  tissue  throughout 
the  brain,  more  marked  when  the  case  is  older  Fig.  219).  Others 
have  found  an  increase  in  the  neuroglia  cells  (Kingsbury).  In  old 
cases  there  is  often  a  chronic  leptomeningitis,  and  vascular  changes 
due  to  the  frequent  congestions  of  the  brain  take  place.  These  con- 
sist in  varicose  and  fusiform  dilatation  of  vessels,  with  evidence  of 
small  hemorrhages.  Slight  degenerative  changes  in  the  nerve  fibres 
are  also  observed. 

Bevan  Lewis  finds  in  epileptics  with  insanity  a  fatty  degenera- 
tion of  the  nuclei  of  the  "  angular  cells  "  of  the  second  layer  of  the 
cortex.  In  the  severer  and  later  stages  of  the  disease  this  nuclear 
degeneration  is  increased  so  that  vacuoles  are  formed.  The  cells 
of  the  deeper  layers  are  also  affected,  but  to  a  less  extent.  The 
change,  though  not  peculiar  to  epilepsy,  is  more  extensive  and  pro- 
nounced in  this  disease. 

To  sum  up:  The  anatomical  basis  of  idiopathic  epilepsy  consists 
in  a  degeneration  of  the  cortical  cells.  Also  a  proliferation  and 
increase  in  the  neuroglia  tissue,  this  occurring  most  markedly  in 
various  islets  or  special  areas  of  the  cortex.  The  blood-vessels  and 
connective  tissue  are  involved  only  secondarily  and  later. 

Physiology. — The  epileptic  fits  are  due  to  sudden  discharges  of 
nerve  force.  The  seat  of  the  discharge  is  the  cortex  of  the  brain. 
The  discharging  cells  are,  in  the  severe  seizures,  the  large  motor 
cells,  the  function  of  which  is  to  store  up  and  discharge  nerve  force. 
They  are  under  control  of  the  sensory  cells  (angular  cells)  of  the 
second  layer,  which  have  an  inhibitory  power.  These  being  dis- 
eased, their  control  is  weakened  and  the  motor  cells  "explode"  peri- 
odically. In  sensory  and  psychical  epilepsy  the  same  mechanism 
exists.  The  more  highly  organized  cells  with  large  nuclei  of  the 
second  layer  are  coiigeuitally  or  otherwise  weak  and  diseased;  the 
cells  below  them  are  not  maintained  in  stable  equilibrium  and  hence 
periodically  break  down  and  "discharge." 

'Idie  diagnosis  is  based  on  the  character  of  the  attacks  and  has  to 
ade  from  hysterical  and  various  toxic  and  symptomatic  convul- 
sions. 

The  aura,  the  scream,  the  quick  loss  of  consciousness,  the  di- 
lated pupils,  the  tonic  convulsion,  the  bitten  tongue,  the  emptied 
bladder,  are  all  characteristic.  The  hysterical  patient:  sometimes, 
but  rarely,  loses  consciousness,  the  epileptic  almost  always.  Hys- 
terical   patients    do    not   hurt   themselves   in   falling  or  bite  their 

:;i 


482  DISEASES    OF   THE    NERVOUS   SYSTEM. 

tongue,  and  their  muscular  movements,  while  irregular  and  violent 
in  character,  are  yet  co-ordinate,  i.e.,  they  throw  themselves  about, 
kick,  strike,  etc.  Their  attacks  often  are  produced  by  emotion  and 
are  ended  by  some  powerful  mental  or  physical  impression.  The 
slight  rise  of  temperature  in  epileptics  rarely  occurs  in  hysterics. 
Petit  mal  and  epileptic  vertigo  are  distinguished  by  the  sudden 
lapse  of  consciousness  and  by  the  sudden  pallor  and  fixation  of  the 
eyes,  dilatation  of  the  pupils,  and  slight  twitchings  of  the  face. 
Nocturnal  convulsions  are  usualty  epileptic. 

Eclampsia,  or  acute  symptomatic  and  reflex  convulsions,  cannot 
always  be  distinguished  from  epilepsy.  The  history  of  the  case, 
the  irregular  and  often  prolonged  character  of  the  fit,  may  enable 
one  to  make  the  diagnosis. 

Course  and  Prognosis. — Epilepsy  shortens  life  to  some  extent; 
most  subjects  do  not  live  beyond  the  age  of  forty  or  fifty.  About 
ten  per  cent  become  demented  or  insane.  Eive  or  ten  per  cent  get 
well.  The  remainder  reach  a  certain  stage  of  severity  in  their  dis- 
ease and  continue  in  it  for  years.  This  severity  depends  on  the 
treatment,  the  nature  of  the  attacks,  and  the  extent  of  degenera- 
tion which  the  organism  shows.  While  unquestionably  treatment 
cures  or  suppresses  the  disease  in  some  cases,  it  disappears  sponta- 
neously in  others.  The  prognosis  of  petit  mal  is  worse  than  that 
of  grand  mal;  that  of  the  two  combined  is  worse  still,  yet  not  hope- 
less. The  psychical  form  of  epilepsy  is  the  least  amenable  to  treat- 
ment. Epileptic  insanity  and  dementia  are  incurable.  Death  oc- 
curs rarely  in  the  attacks  except  in  terminal  stages.  Yet  the  status 
epilepticus  is  always  a  source  of  danger. 

Epileptics  are  said  rather  frequently  to  suffer  from  phthisis. 
This  is,  however,  a  matter  of  infection  and  can  be  prevented.  It 
should  be  remembered  that  epileptics  who  have  only  a  moderate 
number  of  attacks,  six  to  fifteen  yearly,  can  get  along  comfortably 
for  years,  doing  their  work  and  enjoying  a  fair  share  of  the  duties 
and  pleasures  of  life.  Finally,  the  following  prognostic  rules  may 
be  laid  down :  The  prognosis  is  better  in  males,  better  if  there  is  a 
hereditary  history,  better  if  the  fits  are  nocturnal  or  diurnal  alone, 
better  in  grand  mal,  better  if  fits  occur  infrequently,  better  if  they 
begin  after  twenty,  and  better  if  due  to  extrinsic  causes.  The 
prognosis  is  very  bad  in  post-hemiplegic  epilepsy  and  epilepsy  due 
to  organic  disease. 

Treatment. — The  first  and  essential  rule  of  treatment  is  to  take 
cases  early  and  treat  them  vigorously  from  the  start.  Children  who 
have  had  a  few  convulsions  during  the  first  three  or  five  years  of 
life  should  be  treated  as  if  they  might  develop  epilepsy  between  the 


FUNCTIONAL   NERVOUS    DISEASES.  483 

ages  of  ten  and  fifteen  or  earlier.  The  recurrence  of  a  fit  between 
the  ages  of  five  and  ten  should  excite  apprehension  and  call  for  the 
most  diligent  treatment.  Another  rule  is  that  when  epilepsy  is 
recognized  in  children  the  case  should  be  treated  constantly  for  at 
least  three  years  after  all  attacks  have  ceased. 

Constitutional  Treatment. — Along  with  the  evolution  of  epilepsy 
there  is  probably  a  progressive  diffuse  neuroglia  sclerosis  of  the 
brain.  Whether  this  is  primary  or  secondary,  it  is  at  least  proper 
to  use  those  measures  which  apparently  affect  this  neuroglia  pro- 
liferation. Mercury,  arsenic,  and  perhaps  iodide  of  potassium 
are  drugs  which  we  have  good  reason  for  believing  affect  this. 

Besides  this,  Ave  should  use  measures  that  increase  vasomotor 
tone  and  strengthen  and  steady  the  circulation.  Nothing  does  this 
better  than  water.  Epileptics  should  be  given  showers,  douches, 
cold  sponge  baths,  or  wetpacks  according  to  their  needs  and  oppor- 
tunities. They  should  also  drink  water  freely.  Again,  the  nervous 
system  is  greatly  steadied  and  quieted  by  mental  occupation  that 
interests  one.  Nothing  is  more  unfortunate  than  the  idleness  often 
inforced  on  epileptics.  I  have  seen  the  disease  absolutely  checked 
by  having  a  boy  learn  a  trade  that  he  liked. 

The  next  most  important  indication  is  diet,  the  prevention  of 
intestinal  decomposition.  In  petit  vial  particularly  an  absolutely 
non-irritating  diet,  such  as  milk,  meat,  and  bread,  will  quickly  les- 
sen or  stop  the  attacks.  Meats  can  be  taken  in  moderation  if  eaten 
slowly.  As  a  rule  it  is  a  little  safer  to  keep  meat  out  of  children's 
diet  for  a  time ;  but  in  adults  it  is  not  necessary,  though  it  should 
be  given  in  moderation.  • 

Kemoval  of  irritating  causes.  Malaria  if  present  promotes  the 
convulsive, tendency;  so  also  do  lead  and  acohol;  tobacco  does  not 
do  this,  but  its  use  is  better  stopped,  as  it  is  liable  to  weaken  vas- 
cular tone  and  impair  digestion.  Syphilis  causes  epilepsy  only 
through  producing  organic  changes. 

The  rheumatic,  gouty,  and  so-called  tuberculous  diatheses  do  not 
stand  in  any  close  relation  to  epilepsy.  The  condition  known  as 
lithaemia,  however,  in  which  there  are  insufficient  oxidation  and  ex- 
cretion of  products  of  tissue  waste,  needs  attention.  Hence  the  use 
of  bicarb;  mate  of  potassium,  salicylate  of  sodium,  the  alkaline  min- 
eral waters,  and  a  restricted  diet  are  not  rarely  indicated. 

The  importance  of  reflex  irritations  has  been  much  overesti- 
mated. Still  they  must  be  considered.  The  most  serious  are  those 
arising  from  the  gastro-intestinal  tract,  the  sexual  organs,  and  the 
eyes.  Phimosis  if  present  must  be  relieved,  and  masturbation  or 
sexual  excesses  stopped  if  possible.     It  is  admitted  now  that  re- 


484  DISEASES    OF   THE    NERVOUS    SYSTEM. 

moval  of  the  ovaries,  even  if  diseased,  never  cures  true  epilepsy, 
though  it  may  help  hysterical  convulsions. 

Astigmatism  and  hypermetropia  should  be  corrected ;  also  ocular 
insufficiencies  if  these  are  pronounced. 

Proper  attention  to  the  frequent  constipation  and  dyspepsia  is 
of  course  necessary.  The  use  of  hot  water  is  often  serviceable,  a 
glass  being  sipped  slowly  before  the  morning  and  evening  meals. 
This  helps  also  to  carry  off  the  bromides  and  wash  out  the  system 
generally.  Still  further  to  promote  this,  a  purge  should  be  given 
every  fortnight  or  month.  Out-door  life  and  active  physical  exer- 
cise are  indorsed  by  Hippocrates.  They  do  not  have  any  specific 
influence  unless  associated  with  some  employment. 

Specific  treatment.  The  drugs  which  have  obtained  and  held  a 
reputation  as  anti-epileptics  are  not  numerous.  They  are  the  bro- 
mides, chloral,  chloral-amide,  belladonna,  zinc,  nitroglycerin,  anti- 
febrin,  and  antipyrin.  Of  less  value  are  digitalis,  cannabis  in- 
dica,  borax,  valerian,  and  ergot.  As  adjuvant  drugs  we  have  quinine, 
strychnine,  iron,  the  phosphates,  arsenic,  silver,  the  alkalies  and 
iodides.     The  most  valuable  of  the  specific  drugs  are  the  bromides. 

All  bromides  act  alike  in  this  disease.  If  one  does  not  cure  an- 
other will  not.  Occasionally,  changing  or  mixing  reduces  the  attacks 
for  a  time  and  benefits  the  stomach.  The  best  bromides  are  those 
of  potassium,  sodium,  strontium,  ammonium,  and  hydrogen  (hydro- 
bromic  acid).      Pure  bromine  may  be  used. 

Bromide  of  potassium  is  the  most  trustworthy.  Bromide  of  so- 
dium is  more  agreeable  to  the  taste,  less  irritating  to  the  stomach 
and  milder  in  its  effects,  'but  is  eventually  just  as  depressing  as 
other  forms.  Bromide  of  ammonium  has  a  brief  stimulant  effect 
on  the  circulation.  Bromide  of  strontium  has  no  advantages  that 
I  can  discover.     Bromide  of  gold  is  of  no  use. 

Hydrobromic  acid  is  useful  in  those  cases  in  which  there  are 
indigestion  and  phosphaturia  and  an  alkali  is  contraindicated.  It 
produces  acne  less  readily  than  the  alkaline  bromides. 

Bromides  should  be  given  in  daily  doses  of  3  i.,  increased  grad- 
ually until  the  attacks  are  suppressed  or  the  dose  reaches  3  iv.  to 
5  i.  daily.  Few  patients  can  tolerate  more  than  this  latter  dose. 
Thorough  bromidization  should  be  always  tried  if  necessary  to  stop 
the  fits,  and  it  may  be  occasionally  repeated.  But  bromidization 
is  sometimes  injurious,  even  making  the  disease  worse,  and  it  must 
always  be  employed  with  caution.  When  the  fits  are  suppressed 
the  bromides  should  be  reduced,  but  never  entirely  stopped  for  at 
least  two  years  after  the  last  fit.  In  most  cases,  and  especially  in 
nocturnal  epilepsy,  an  extra  large  dose  of  bromide  or  bromide  and 


FUNCTIONAL    NERVOUS    DISEASES.  485 

chloral  should  be  given  at  night.  It  is  very  important  that  the  bro- 
mides should  be  chemically  pure  (most  samples  are  not),  that  their 
use  should  be  continued  a  very  loug  time,  and  that  their  depressing 
effects  should  be  offset  by  tonics  and  all  possible  roborant  measures. 

Bromides  lessen  the  fits  in  from  eighty  to  eighty-five  per  cent 
of  cases.  They  do  no  good  or  do  actual  harm,  as  regards  frequency 
of  attacks,  in  from  five  to  ten  per  cent  of  cases.  Bromides  do  no 
actual  good  to  the  patient  in  a  much  larger  proportion  of  cases. 

To  prevent  bromide  acne,  arsenic,  calcium  sulphide,  baths,  and 
diuretics  are  the  best  measures. 

To  prevent  brumidization,  one  should  adopt  all  possible  roborant 
measures;  use  salt-water  baths  and  regular  physical  exercise;  give 
black  coffee,  caffeine,  cocaine,  mineral  acids,  strychnine,  bitter 
tonics,  cod-liver  oil.  In  all  cases  the  patient  should  dilute  the 
drug,  preferably  with  carbonic-acid  water  or  Vichy,  in  the  propor- 
tion of  six  ouuces  of  water  to  a  scruple  of  the  drug.  A  few  drops 
of  phosphoric  acid  may  be  added  to  this. 

The  continuous  administration  of  an  alkaline  bromide  in  an  alka- 
line water  sometimes  affects  the  bladder,  and  then  the  bromide  can 
be  given  dissolved  in  hydrobromic  acid. 

The  best  substitutes  for  the  bromides,  when  these  do  no  good  or 
do  harm,  are  belladonna,  zinc,  strychnine,  glonoin,  borax,  and  anci- 
pyiin. 

The  best  non-specific  adjuvants  (drugs)  to  the  bromides  are  po- 
tassium iodide  (in  syphilitic  epilepsy),  carbonate  and  sodium  sali- 
cylate (in  lithaemic  and  rheumatic  states),  carbonate  of  ammonium, 
the  hypophosphitea,  arsenic,  iron,  and  quinine. 

One  of  the  best  specific  adjuvants  to  the  bromides,  as  Seguin  has 
shown,  is  chloral  hydrate.  By  adding  five  or  six  grains  of  this  to  a 
mixture  the  bromide  dose  can  be  reduced  one-half  and  the  fits  still 
be  controlled.  Chloral-amide  has  a  similar  effect.  Both  these  drugs 
will  sometimes  affect  the  eyes  and  stomach  unfavorably.  Other  ex- 
cellent adjuvants  are  salicylate  of  sodium  and  antipyrin.  Children 
bear  nearly  as  large  doses  of  bromide  as  adults. 

The  remedies  that  are  especially  useful  in  petit  m<il  are,  after  the 
bromides,  antipyrin,  bromide  of  camphor,  belladonna,  glonoin,  can- 
nabis indica,  cod-liver  oil,  ergot,  counter-irritation  at  the  back  of 
the  neck,  and  cold  spinal  douches. 

For  epilepsy  in  children,  besides  the  bromides  it  is  sometimes 
advisable  to  employ  milk  diet,  rest,  and  oxide  of  zinc. 

In  hemiplegic  and  in  Jacksonian  epilepsy  the  actual  cautery  ap- 
plied over  the  scalp  is  beneficial.  Urethane  occasionally  acts  well 
also,  but  it  is  of  no  use  in  ordinary  epilepsy  and  it  may  produce 


480  DISEASES    OF    THE    NERVOUS    SYSTEM. 

albuminuria  if  given  in  large  closes.  Strychnine  is  sometimes  use- 
ful. Raising  the  head  of  the  bed  or  making  the  patient  sleep  in  a 
chair  at  night  are  measures  that  may  be  tried. 

For  hysterical  and  erethitic  cases,  with  or  in  place  of  bromides 
give  a  diet  of  milk  and  vegetables,  and  try  turpentine,  valerian,  or 
zinc.     Belladonna  is  usually  contraindicated. 

Counter-irritation  by  means  of  blisters,  issues,  and  setons  at  the 
back  of  the  neck  is  of  doubtful  value. 

For  the  status  epilepticus  give  large  enemata  of  chloral  and  use 
emetics  and  purges.  Venesection  is  often  efficacious,  morphine  is 
dangerous,  chloroform  is  only  palliative,  and  nitrite  of  amyl  is  of 
little  value. 

To  prevent  impending  attacks  the  best  remedy  is  nitrite  of  amyl, 
which  may  be  carried  in  a  phial  filled  with  cotton.  Inhalation  of 
chloroform  or  ammonia,  the  internal  administration  of  ammonia, 
spirits  of  lavender,  or  alcohol,  a  sternutatory,  and  pressure  on  the 
carotids — all  are  measures  which  sometimes  stop  the  attack. 

Alterative  and  habit-breaking  drugs,  such  as  mercury,  iodide  of 
potassium,  arsenic,  and  antimony,  are  useful  in  epilepsy,  especially 
in  acquired  forms  due  to  lead,  alcohol,  and  syphilis.  Bromides 
stop  the  fits  oftener  if  given  early  in  the  disease,  if  given  to  young 
children,  and  if  given  in  cases  that  develop  after  twenty-one. 

Injuries  to  the  head  which  have  caused  a  fracture  or  a  contusion 
of  the  brain  are  the  most  frequent  traumatic  irritants.  Whenever 
epilepsy  can  be  distinctly  traced  to  a  blow  on  the  head  the  question 
of  trephining  should  be  brought  up.  If  there  is  a  history  of  frac- 
ture, or  present  evidence  of  fracture,  or  even  evidence  of  severe  head 
injury,  trephining  is  justifiable.  The  more  marked  the  evidence  of 
a  degenerative  constitution  and  the  less  marked  the  evidence  of  real 
brain  injury,  the  less  hopeful  the  prognosis.  On  the  whole,  surgery 
can  do  little  for  acquired  and  nothing  for  idiopathic  epilepsy. 


CHAPTER  XXIII. 

HYSTERIA. 

Hysteria  is  a  chronic  functional  disorder  characterized  by  ner- 
vous crises  of  an  emotional,  convulsive,  or  other  nature  and  by  an, 
inter  paroxysmal  state  in  which  certain  marks  or  stigmata  are  pres- 
ent. Hysteria  is  essentially  a  psychosis,  and  the  dominant  symp- 
toms are  attributable  to  disorder  of  the  cortical  areas  of  the  brain. 
Its  components  are  the  paroxysms,  or  "  crises  "  as  they  are  called, 
on  the  one  hand,  and  the  peculiar  symptoms  of  an  inter  paroxysmal 
state  on  the  other  hand.  The  disease  is  to  be  regarded  as  a  definite- 
one,  having  a  certain,  as  yet  unknown,  pathological  basis  underly- 
ing it.  The  use  of  the  word  should  be  much  more  restricted  and 
definite  than  has  hitherto  been  the  fashion.  There  are  two  forms- 
of  the  disease,  hysteria  major  and  hysteria  minor. 

Etiology. — Of  the  predisposing  causes  heredity  is  the  most  im- 
portant. In  about  seventy-five  per  cent  there  is  a  history  of  hys- 
teria or  some  neurosis  or  psychosis  in  the  parents.  The  disease  is 
transmitted  more  often  by  the  mother.  Heredity  is  particularly  apt 
to  be  important  in  the  hysteria  of  children;  it  is  a  much  smaller 
factor  in  hysteria  of  adult  males.  A  hereditary  history  of  rheu- 
matism, gout,  and  tuberculosis  is  of  very  doubtful  importance. 
Hysteria  is  a  disease  of  early  adult  life,  most  cases  occurring  be- 
tween the  ages  of  from  fifteen  to  twenty-five  in  females;  it  occurs 
later  in  males.  Hysteria  attacks  children  between  the  ages  of  eight 
and  fifteen,  chiefly  between  eleven  and  fourteen.  The  disease  af- 
fects women  more  than  men  in  the  proportion  of  four  to  one,  vary- 
ing much  with  race,  climate,  and  occupation.  Hysteria  occurs  in 
all  classes  of  life,  but  rather  less  frequently  in  the  middle  classes 
than  among  the  poor  and  the  very  rich.  Male  hysteria  is  more  fre- 
quent in  the  poorer  classes  who  are  subjected  to  the  exciting  influ- 
ences of  alcoholism,  poverty,  injuries,  etc.  Hysteria  is  certainly 
much  less  frequent  in  its  severer  forms  in  this  country  than  in  some 
parts  of  Europe,  particularly  France.  In  my  experience  it  is  much 
less  frequent  than  epilepsy  in  the  northern  and  eastern  parts  of  this 
country.  It  occurs,  however,  quite  frequently  in  the  negroes  and 
also  in  the  Latin  races  of  this  country.     Bad  methods  of  education. 


488  DISEASES   OF   THE    NERVOUS   SYSTEM. 

and  bad  family  training  undoubtedly  tend  to  promote  the  develop- 
ment of  the  disease. 

The  most  important  single  exciting  factor  is  powerful  emotion, 
particularly  fear.  Other  emotions  of  an  allied  character — excite- 
ment, sorrow,  anxiety — may  bring  on  attacks.  The  disease  can  be 
developed  by  imitation.  Injuries  combined  usually  with  mental 
shock  are  fruitful  causes  of  producing  hysteria.  The  infectious 
fevers,  syphilis,  diffuse  hemorrhages,  the  poisons — lead,  alcohol, 
mercury,  and  tobacco — the  administration  of  ether,  mental  and 
bodily  and  sexual  excesses,  are  all  important  agents  in  developing 
the  disease. 

Symptoms. — The  symptoms  of  hysteria  are  best  described  under 
two  general  heads :  first,  those  of  hysteria  minor  or  the  hysterical 
condition,  and  second,  those  of  hysteria  major. 

1.  Hysteria  minor  is  characterized  by  the  interparoxysmal  con- 
dition of  emotional  weakness,  nervousness,  hyperesthesia  and  pains, 
and  by  crises  of  an  emotional  character.  In  hysteria  minor  there 
are  no  permanent  objective  marks  like  anaesthesia  and  paralysis, 
and  no  decided  convulsive  seizures.  The  patient,  who  is  almost  al- 
Avays  a  girl  or  young  woman,  gradually  develops  an  undue  sensitive- 
ness, the  mind  is  depressed,  and  she  gets  easily  alarmed.  She  has 
feelings  of  nervousness  and  lacks  control  over  the  emotions,  she 
laughs  and  cries  very  easily  and  yields  to  every  impulse.  She  suf- 
fers from  headaches,  which  are  usually  vertical  and  often  severe  and 
chronic,  and  from  spinal  pains.  She  sleeps  as  a  rule  rather  badly 
and  often  has  disagreeable  dreams.  She  has,  under  any  little  ex- 
citement, sensations  of  tickling,  fulness  or  choking  in  the  throat, 
forming  the  condition  known  as  globus.  Excitement  also  brings 
on  attacks  of  trembling  or  chilly  feelings  which  come  and  go.  There 
is  more  rarely  a  considerable  amount  of  vasomotor  instability,  as 
shown  by  flushings  and  by  coldness  of  the  extremities. 

She  has  with  more  or  less  frequency  distinct  crises  of  an  emo- 
tional character,  during  which  she  laughs  or  cries  Without  apparent 
cause,  or  at  least  to  an  extent  beyond  her  control.  She  may  have 
attacks  of  vomiting  or  headache,  or  of  intense  mental  excitement 
amounting  almost  to  delirium.  In  some  cases  the  patient  has  som- 
nambulic attacks  at  night,  or  she  may  have  under  a  little  excitement 
attacks  of  cerebral  automatism  during  which  she  involuntarily  does 
things  that  she  is  entirely  uuconscious  of  when  she  comes  out  of  the 
attack.  The  crises  are  followed  by  a  copious  discharge  of  very  light 
urine.  Hysteria  minor  is  closely  allied  to  a  condition  of  neuras- 
thenia or  of  simple  nervousness.  It  is  associated  with  neurasthenia 
oftentimes,  and  is  to  be  distinguished  from  it  chiefly  by  the  peculiar 


HYSTERIA.  489 

psychical  state,  the  hypereesthesia,  and  the  crises  which  have  been 
described.  Even  in  hysteria  minor  there  is  a  degree  of  that  pecu- 
liar mental  condition  which  will  be  described  later  and  which  is 
known  as  suggestibility.  Hysteria  minor  is  a  disease  which  belongs 
especially  to  childhood  and  early  womanhood.  It  is  very  apt  to 
become  ameliorated  and  disappear  a  little  later  in  life  or  under  the 
influence  of  proper  treatment,  but  it  ma}-  continue  or  pass  into  the 
major  form. 

2.  Hysteria  major  is  characterized  by  interparoxysmai  mani- 
festations of  anaesthesia,  paralyses,  contractures,  tremors,  peculiar 
mental  conditions,  and  by  paroxysms  of  an  emotional,  convulsive, 
or  other  serious  nature.  Hysteria  major  is  what  is  usually  meant 
when  one  speaks  of  hysteria;  it  includes  also  hystero-epilepsy. 
The  onset  may  be  gradual,  but  not  infrequently  it  follows  some 
shock,  the  first  symptom  being  a  convulsion,  a  paralysis,  or  some 
emotional  outburst. 

The  symptoms  of  the  crises  are  the  most  striking  and  will  be  de- 
scribed first.  The  most  common  of  the  paroxysms  of  hysteria  are 
emotional  outbursts  of  crying  or  laughing;  after  this  come  motor 
disturbances  in  the  shape  of  convulsions  of  various  types  or  of  hemi- 
plegia or  other  type  of  paralysis.  Besides  this  Ave  have  attacks  of 
severe  pain,  forming  neuralgic  crises;  attacks  of  nausea,  gastral- 
gia,  and  vomiting,  forming  gastric  crises ;  much  more  rarely  there 
are  prolonged  attacks  of  hysterical  coughing,  hiccoughing,  sneezing, 
or  rapid  breathing.  The  hysterical  seizure  may  also  take  the  form 
of  attacks  of  trance  and  lethargy,  catalepsy,  amnesia,  and  cerebral 
automatism. 

The  emotional  crises  are  characterized  by  appearing  without  any 
good  cause ;  the  patient  laughs  without  reason,  and  the  laughing 
continues  and  is  quite  beyond  her  power  of  control.  In  the  same 
way,  and  rather  more  frequently,  crying  attacks  or  attacks  of  furi- 
ous anger  and  excitement  come  on.  Associated  with  these  outbursts 
there  is  almost  always  a  peculiar  sensation  of  something  in  the 
throat.  It  is  described  sometimes  as  being  a  ball  or  pressure  or  a 
squeezing  sensation.  It  is  called  hysterical  globus,  and  is  due  usu- 
ally to  a  paresthesia  of  the  nerves  of  the  throat  and  larynx,  but 
occasionally  there  is  also  a  muscular  spasm  of  those  parts.  Fol- 
lowing the  i  rises  there  is  a  profuse  discharge  of  pale,  limpid  mine. 

Hysterical  convulsions  have  two  rather  well-defined  types.  One 
of  thein  is  that  which  comes  on  also  in  hysteria  minor  and  is  the 
ordinary  form  of  hysterical  convulsions;  the  other  is  a  much  more 
severe  disturbance  in  every  way  and  is  known  as  a  hystero-epileptitJ 
or  hysteroid  attack.     In  the  hysterical  convulsion  the  patient,  under 


■490  DISEASES   OF   THE    NERVOUS    SYSTEM. 

the  influence  of  some  excitement,  injury,  or  acute  gastric  disturb- 
ance, rather  suddenly  falls  down  and  begins  to  go  through  various 
irregular  movements  of  the  body,  such  as  thrashing  with  the  arms, 
kicking  with  the  legs,  throwing  the  head  from  side  to  side,  rolling 
about  on  the  bed  or  floor.  In  the  more  distinctively  convulsive  seizure 
the  hands  and  arms  and  fingers  are  flexed,  the  legs  and  feet  are  ex- 
tended, the  eyes  are  generally  closed,  the  eyeballs  often  converged 
or  moved  about  irregularly,  the  pupils  dilated.  There  is  some  les- 
sening of  sensation  over  the  body  and  of  the  conjunctivae.  The  pa- 
tient often  utters  noises  or  screams  at  intervals.  She  may  bite  her 
lips,  but  does  not  bite  the  tongue,  nor  does  she  ever  hurt  herself  in 
her  various  contortions.  The  attack  may  last  for  half  an  hour  to 
several  hours,  unless  some  measures  are  taken  to  break  it  up.  In 
other  forms  of  hysterical  convulsion  there  is  simply  a  general  shak- 
ing or  trepidation  of  the  body  as  though  the  patient  had  a  chill;  in 
other  cases  again  the  main  type  of  movement  is  that  of  opisthot- 
onos, the  patient  rising  up  upon  the  head  and  heels  and  arching 
the  body  as  in  tetanus.  Again  the  attack  may  consist  simply  of  a 
little  rigidity  of  the  body,  or  of  a  series  of  rhythmical  movements 
of  the  head  or  trunk  or  limbs,  the  patient  sitting  up  and  oscillating 
the  head  or  swaying  the  trunk  or  moving  the  arms,  littering  at  the 
same  time  incoherent  words.  In  still  other  cases  the  patient  sim- 
ply falls  doAvn  and  lies  unconscious  like  a  person  sleeping  for  a  few 
minutes  or  even  an  hour.  In  children  the  attacks  may  be  asso- 
ciated with  peculiar  noises  and  movements  in  imitation  of  animals, 
such  as  the  growling  of  a  dog  or  the  mewing  of  a  cat.  This  condi- 
tion is  called  therio-mimicry.  In  some  instances  the  attack  may 
be  accompanied  by  or  may  end  in  a  condition  of  mental  excitement 
approaching  delirium.  The  patients  while  suffering  from  these 
seizures  generally  appreciate  what  is  going  on  about  them,  and  will 
often  respond  to  some  stern  order  for  them  to  cease  or  will  be 
brought  to  a  state  of  quietude  by  pressure  upon  some  part  of  the 
body  which  provokes  pain.  In  women  in  particular,  pressure  over 
the  ovaries  or  epigastrium  will  abort  the  attack ;  the  application  of 
cold  water  or  an  emetic  will  do  the  same. 

After  a  hysterical  crisis,  or  sudden  shock,  the  patient  may  be 
found  to  have  a  paralysis  of  arms  or  legs  or  one  side  of  the  body. 

The  Symptoms  of  the  Inter  paroxysmal  State. — Between  the  crises 
the  patient  may  be  in  a  fair  condition  of  general  health,  but  usually 
presents  certain  definite  chronic  manifestations  of  the  disease.  The 
most  characteristic  are  sensory  symptoms,  paralyses,  and  contrac- 
tures. 

Sensory  symptoms.      These  consist  of  cutaneous   and   mucous 


HYSTEKIA.  491 

hyperesthesia  and  anaesthesia  and  anaesthetic  disturbances  of  the 
special  senses.  Cutaneous  anaesthesia  occurs  in  three  forms:  the 
common  form  is  that  of  hemianesthesia  involving  one-half  of  the 
body ;  next  in  frequency  is  the  segmental  anaesthesia  involving  an  arm 
or  a  leg  or  part  of  the  face  or  head ;  rarest  of  all  the  forms  is  a  dis- 
seminated anaesthesia  occurring  in  the  form  of  patches.  These 
various  modes  of  distribution  are  shown  in  the  accompanying  figures. 
The  anaesthesia  is  a  pain  anaesthesia  chiefly.  The  tactile  and  thermic 
sensations  are  less  markedly  affected.  The  anaesthesia  is  in  some  rare 
cases  transferable  by  means  of  magnets  or  electrical  irritants  or  by 
suggestion.  The  anaesthesia  can  also  be  lessened  or  removed  tempo- 
rarily by  the  application  of  magnets  or  coins  or  pieces  of  metal.  For 
example,  if  a  silver  coin  is  fastened  upon  the  anaesthetic  area,  in  the 
course  of  a  few  minutes  or  a  few  hours  there  will  be  a  zone  of  normal 
sensation  under  and  around  the  coin.  Sometimes  the  temperature 
of  the  skin  upon  the  anaesthetic  part  is  lowered  3°  or  4°  ¥.,  and  upon 
pricking  the  skin  blood  does  not  flow.  The  anaesthesia  is  oftener 
upon  the  left  side  in  the  proportion  of  three  to  one.  Hysterical  anaes- 
thesias are  not  accompanied  by  subjective  sensations  as  are  organic 
anaesthesias.  The  skin  reflex  is  usually  abolished.  Anaesthesia 
of  some  kind  occurs  in  a  very  large  proportion  of  chronic  forms  of 
hysteria  major.  They  are  rare,  however,  in  children,  and  are 
rarer  in  women  than  in  men,  in  the  author's  experience.  Anaes- 
thesia of  the  mucous  membranes  is  present  chiefly  in  hemianes- 
thesia; it  then  involves  the  mucous  membrane  of  the  mouth  and 
throat,  and  to  a  less  extent  that  of  the  nose  and  glottis.  Henri- 
anaesthesia  is  usually  accompanied  by  some  hemiplegia  and  often 
by  some  tremor.  Segmental  anaesthesia  is  also  often  accompanied 
by  some  degree  of  paralysis  of  the  part. 

Visual  anaesthesias.  One  of  the  most  common  of  the  perma- 
nent stigmata  of  hysteria  is  an  anaesthetic  condition  of  the  retina. 
The  result  of  this  is  the  production  of  a  concentric  limitation  of 
the  visual  field  and  a  disturbance  in  the  color  sense.  Complete 
loss  of  this  sense  may  take  place  or  there  may  be  a  variation  in 
the  ways  in  which  the  colors  are  perceived.  There  may  be  also 
a  distinct  diminution  in  the  acuity  of  vision  or  even  a  complete 
loss  of  sight  of  one  eye.  The  visual  disturbance  is  most  common 
with  hemianaesthesia.  It  is  more  marked  on  the  affected  side, 
but  exists  to  some  extent  on  the  healthy  side.  The  limitation  of 
the  fields  is  shown  in  the  accompanying  cut  (Fig.  221). 

Hearing.  There  is  sometimes  a  diminution  in  the  acuity  of 
hearing  of  one  ear.  and  this  occurs,  if  present,  in  connection  with 
hemianaesthesia.     There  may  also   be  a  loss  of   hearing  to  high 


492 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


and  low  notes,  while  hearing  is  apparently  fairly  good  to  notes  of 
medium  range ;  and  finally  there  may  be  a  diminution  in  hearing 


Fig.  220.- The  Three  Types  op  Distribution  op   Anaesthesia  in  Hysteria*     Hemi- 
anesthesia, Segmental,  and  Disseminated.     2T,  hysterogenic  zones. 

by  bone  conduction,  while  hearing  by  aerial  conduction  is  but  little 
impaired,  this  being  due  probably  to  an  anaesthesia  of  the  acoustic 
nerve. 


o.  s. 


O.  D. 


Fig.  221 .  —Hysterical  Loss  op  Color  Sense  and  Limitation  of  Visual  Field. 
Color  sense  absent  in  left  eye  and  field  contracted;  in  right  eye  field  less  contracted ;  order 
of  appreciation  of  colors  from  without  in  was  yellow,  violet,  blue,  red,  green  (observation 
by  Dr.  E.  S.  Peck). 

Disturbances  of  taste  in  the  form  of  anaesthesia  or  paraesthesia 
are  quite  frequent  and  are  important  signs  in  hysteria.     The  loss 


HYSTERIA.  493 

of  the  sense  of  taste  may  involve  only  the  back  portion  of  the 
tongue  and  the  palate ;  in  other  words,  the  taste  field  is  here  lim- 
ited as  it  is  with  hearing  and  vision. 

The  sense  of  smell  may  be  abolished,  but  this  usually  occurs 
in  connection  with  hemianesthesia. 

Hyperesthesias  and  neuralgias.  Pure  neuralgias  are  someAvhat 
rare  in  true  hysteria,  hut  hyperesthesia  and  pains  of  various  kinds 
are  not  at  all  infrequent.  Hyperesthesia  occurs  in  the  form  of 
patches  at  different  parts  of  the  body.  These  sensitive  points  may, 
when  pressed  upon,  bring  on  paroxysms  of  various  kinds,  and  they 
are  therefore  called  the  hysterogenic  zones  (Fig.  220).  The  most 
common  seat  of  these  zones  in  women  is  over  the  ovaries ;  in  men, 
in  regions  corresponding  to  'che  ovaries  and  on  the  scrotum.  Hys- 
terogenic zones,  however,  may  be  found  just  beneath  the  mam- 
mary gland,  on  the  epigastrium,  alcng  the  spine,  and  in  other 
places.  These  zones  are  sensitive  areas;  they  can  be  made  to  dis- 
appear by  applications  of  electricity  and  by  refrigeration  and 
counter-irritation.  Hysterical  patients  often  suffer  from  local 
headaches,  which  are  apt  to  be  confined  to  the  top  of  the  head 
or  to  the  sides  near  the  temples.  The  pain  is  severe,  sharp,  and 
boring,  and  may  exacerbate  with  such  intensity  as  to  produce 
symptoms  almost  resembling  meningitis.  The  spot-like  pains  are 
known  as  hysterical  clavus.  Hysterical  patients  occasionally 
have  migraine,  facial  neuralgia,  and  intercostal  neuralgia.  Much 
more  often  they  have  pains  along  the  spine,  producing  symptoms 
of  spinal  irritation.  Hysterical  patients  also  have  at  times  attacks 
of  palpitation  and  pains  over  the  heart,  constituting  what  is  known 
as  pseudo-angina.  Such  troubles  are  much  more  frequent  in 
women. 

Motor  symptoms.  The  motor  symptoms  of  hysteria  are  paraly- 
ses, amyosthenia,  contractures,  tremor,  and  choreic  and  ataxic 
movements.  The  paralyses  of  hysteria  take  the  form  of  hemi- 
plegia, paraplegia,  and  monoplegias.  Hysterical  hemiplegia  oc- 
curs usually  rather  suddenly,  often  as  the  result  of  some  severe 
shock.  The  left  side  is  more  frequently  attacked.  The  arm  is 
most  affected,  the  leg  next,  while  the  face  is  hardly  ever  involved. 
The  paralysis  is  not  an  absolute  one,  and  the  patient  is  able  to  drag 
himself  along.  The  deep  reflexes  arc  usually  not  exaggerated  and 
they  may  be  for  a  short  time  absent.  The  paralysis  is  thus  a  flaccid 
one.  The  gait  of  the  patient  is  different  from  that  of  hemiplegia 
due  to  organic  disease;  in  hysterical  hemiplegia  the  patient  drags 
the  paralyzed  leg  after  him,  in  organic  hemiplegia  the  patient  swings 
the  paralyzed  leg  around  in  a  half  circle.     This  peculiarity  of  tin-  gait, 


494  DISEASES    OF   THE    NERVOUS    SYSTEM. 

the  absence  of  exaggerated  reflexes,  the  absence  of  paralysis  of  the 
face,  and  the  presence  very  commonly  of  other  hysterical  stigmata  are 
sufficient  to  enable  one  to  make  the  diagnosis.  Sometimes  the  face  on 
the  affected  side  is  slightly  drawn  by  a  spasm,  so  that  it  appears  to 
be  paralyzed  when  it  really  is  not  (Charcot).  Monoplegias  affect 
the  arm  or  leg,  very  rarely  indeed  the  face,  occasionally  the  eye 
muscles,  and  most  commonly  of  all  the  muscles  of  the  larynx. 
Hysterical  monoplegia  is  usually  accompanied  by  anaesthesia  of 
the  affected  part  and  by  other  symptoms  of  hysteria.  There  are 
no  serious  atrophic  changes  or  disturbances  of  the  electrical  reac- 
tions. Hysterical  eye  palsies  show  themselves  in  the  form  oftenest 
of  an  insufficiency  of  the  internal  recti,  much  more  rarely  by  a  pa- 
ralysis of  the  third  nerve  or  some  of  its  branches.  In  hysterical 
palsy  of  the  larynx  the  adductors  are  involved  so  that  the  patient 
cannot  speak  loud,  and  the  condition  is  called  hysterical  aphonia. 
The  trouble  often  comes  on  suddenly,  the  patient  finding  that  he 
cannot  speak  above  a  whisper.  The  paralysis  is  not  so  great  but 
that  the  adductors  can  be  approximated  in  coughing.  The  trouble 
is  distinguished  from  laryngeal  inflammation  by  inspection  of  the 
affected  part.  The  abductors  of  the  larynx  and  the  tongue  and 
other  muscles  of  articulation  are  in  very  rare  cases  also  involved, 
and  hysteria  may  produce  symptoms  resembling  a  bulbar  paralysis. 
Paraplegia  is  a  rather  common  form  of  hysterical  palsy ;  it  is  usu- 
ally brought  on  by  emotions  of  depressing  character,  often  associated 
with  some  slight  injury.  It  may  be  accompanied  by  a  good  deal 
of  pain  in  the  back,  and  the  form  of  disease  which  is  popularly 
known  as  "  spinal  concussion"  consists  in  many  cases  of  hysterical 
paraplegia  combined  with  hysterical  neuralgia  of  the  spine.  In 
hysterical  paraplegia  there  is  very  little  wasting  of  the  limbs  and 
no  change  in  the  electrical  reactions.  The  deep  reflexes  may  be 
somewhat  increased  or  normal;  they  are  never  absent.  There  is 
never  any  prolonged  or  persistent  ankle  clonus,  but  there  may  be 
a  short  or  spurious  clonus  due  to  a  general  exaggerated  irritability 
of  the  nervous  system.  The  sphincters  are  never  involved  except 
temporarily  or  through  some  complication. 

Amyosthenia  is  a  frequent,  peculiar,  and  interesting  symptom 
occurring  in  the  inter  paroxysmal  stage  of  hysteria.  It  consists  in 
a  more  or  less  temporary  feeling  of  weakness  of  an  arm  or  of  the 
legs.  Thus  a  person  in  lifting  a  dish  from  the  table  suddenly  feels 
the  arm  give  out,  and  if  not  careful  the  dish  is  dropped;  or  while 
walking  the  patients  suddenly  feel  as  though  they  had  lost  all 
power  in  the  lower  limbs.  This  amyosthenic  condition  is  gener- 
ally temporary,  but  it  may  be  so  permanent  as  to  produce  a  cer- 


HYSTERIA. 


495 


tain  degree  of  monoplegia  or  paraplegia.  The  amyosthenic  con- 
dition generally  precedes  a  paralysis.  It  presents  no  objective 
signs  in  the  way  of  electrical  reaction ;  it  involves  a  whole  mem- 
ber, not  a  single  group  of  muscles;  it  affects  more  the  anaesthetic 
side,  and  when  it  exists  the  deep  reflexes  are  usually  exaggerated 
(Tourette). 

Contractures.  In  some  forms  of  hysteria  there  is  a  tendency 
for  the  muscles  to  undergo  contracture  under  slight  mechanical 
stimulation  such  as  pressure  or  a  blow.  This  tendency  to  con- 
tracture in  hysteria  is  called  the  contractural  diathesis,  and  it  is 
an  important  sign.     The   contractures  may  be  temporary,   disap- 


Fig.  222.  — Hysterical  Contracture  of  the  Hand  of  Six  Months'  Duration. 


pearing  soon  after  the  exciting  cause  ceases,  or  they  may  develop 
independently  and  last  for  a  long  time.  They  involve  the  legs, 
arms,  and  facial  muscles,  and  may  be  associated  with  paralysis 
and  anaesthesia  (Figs.  222,  223). 

Tremor  occurs  in  hysteria  in  a  considerable  proportion  of  cases, 
more  especially  those  in  which  there  are  hemiplegia  and  hemianes- 
thesia. Hysterical  tremor  simulates  all  the.  various  types.  The 
common  form  is  one  in  which  the  oscillations  occur  from  five  and 
a  half  to  seven  and  a  half  times  a  second,  and  it  is  therefore  a 
tremor  of  slow  rhythm.  It  ceases  for  a  time  when  the  person 
is  quiet  or  lies  in  the  horizontal  position ;  also  during  sleep.  It 
affects  the  head  and  tongue  as  well  as  the  extremities,  the  latter 
more  upon  one  side  than  the  other.  It  may  be  chiefly  in  the  lower 
limbs.     Sometimes  it  has  the  type  of  an  intentional  tremor,  ceas- 


496  DISEASES   OF   THE    NERVOUS   SYSTEM. 

ing  on  rest  of  the  hand  and  increasing  when  the  hand  is  moved,  as 
in  raising  a  glass  to  the  lips  (Fig.  224).  It  then  resembles  exactly 
the  tremor  of  multiple  sclerosis.  There  may  be  a  slow  tremor  of 
four  to  five  and  a  half  oscillations  per  second ;  this  persists  during 


Fig.  223.— Hysterical  Contractures. 

rest  and  is  but  little  modified  by  voluntary  movements.  It  imitates 
the  tremor  of  paralysis  agitans.  Finally  there  may  be  a  rapid 
tremor  of  eight  to  nine  oscillations  per  second.  This  also  persists 
during  repose  and  is  but  little  modified  by  movements.  It  imi- 
tates the  tremor  of  Basedow's  disease,  alcoholism,  and  neuras- 
thenia. 

The  mental  state  in  hysteria  is  characterized  by  emotional  in- 
stability and  intense  craving  for  sympathy,  weakness  of  the  will, 
lack  of  self-control,  acuteness  of  perception,  and  a  constant  vari- 


Repose.  Movement. 

Fig.  224.—  Illustrating  Intentional  Tremor  in  Hysteria  (Tourette). 

ability  of  moods.  The  hysterical  mind  is  not  a  dull  one,  it  is  not 
a  consciously  mendacious  or  evil  one.  But  there  are  an  abnormal 
increase  of  sensibility  and  an  exaggeration  of  the  personal  feeling 
or  egotism  which  leads  to  selfishness  and  prompts  deceit. 

The  fundamental  defect  in  the  hysterical  brain  is  that  it  is  cir- 
cumscribed in  its  associative  functions;  the  field  of  consciousness  is 


HYSTERIA.  497 

limited  just  as  is  the  field  of  vision.  The  mental  activity  is  con- 
fined to  personal  feelings,  which  are  not  regulated  by  connotation 
of  past  experiences;  hence  they  flow  over  too  easily  into  emotional 
outbursts  or  motor  paroxysms.     The  hysterical  person  cannot  think. 

Physiologically  the  condition  is  explained  by  supposing  that 
there  is  a  benumbing  of  the  association  fibres  which  normally  con- 
nect sensory  cortical  centres  with  other  parts  and  enable  one  to 
compare  and  adjust  new  experiences  with  old — in  other  words, 
to  reason  and  form  correct  judgments.  Her  mental  life  is  mainly 
in  the  sensory -motor  centres  rather  than  in  the  "  association  centres" 
of  Flechsig.     It  is  a  return  to  the  unripe  brain  of  childhood. 

Underlying  the  hysterical  mental  state  there  is  a  condition  of 
suggestibility,  by  reason  of  which  ideas  and  impressions  easily  be- 
come fixed  and  dominate  the  mind.  The  person  becomes  self- 
hypnotized  and  believes  he  or  she  is  suffering  from  things  which 
have  no  objective  existence.  The  pains,  palsies,  and  anaesthesias 
of  hysteria  major  are  pseudo-delusions,  differing  from  delusions 
of  the  insane  in  that  the  false  belief  or  idea  is  a  subconscious  one. 

Trophic  disorders.  In  hysterical  paralysis  a  slight  amount  of 
atrophy  occurs,  but  only  such  as  would  naturally  follow  disuse  of 
the  part.  A  very  few  cases  have  been  reported  in  which  a  true 
neurotic  atrophy  resembling  the  atrophy  that  occurs  in  neuritis  or 
progressive  muscular  atrophy  was  present,  and  it  is  even  affirmed 
that  degenerative  reactions  may  be  elicited.  Cutaneous  eruptions 
and  dystrophies  practically  do  not  exist,  or,  if  present,  are  the 
result  of  complicating  disorders. 

Visceral  symptoms.  Hysterical  patients  often  suffer  from  dys- 
pepsia and  constipation,  also  from  anorexia  and  in  some  cases  from 
persistent  vomiting  or  regurgitation  of  food.  Occasionally  the 
anorexia  and  vomiting  become  persistent;  the  patient  refuses  food 
or  rejects  all  that  is  taken;  she  emaciates,  becomes  weak  and  bed- 
ridden, and  develops  into  that  particular  phase  of  hysteria  known 
as  "the  fasting  girl."  In  these  cases,  along  with  the  aversion  to 
food  and  vomiting,  there  may  lie  a  great  deal  of  gastralgia.  The 
urine  in  hysteria  is  apt  to  be  of  low  specific  gravity.  Always  after 
hysterical  attacks  there  is  a  profuse  flow  of  very  light-colored  urine 
having  a  gravity  of  only  1.003  to  1.00G.  Sometimes  there  is  re- 
tention of  urine;  in  extremely  rare  eases  there  is  a  condition  known 
as  ischuria  and  anuria,  in  which  for  several  days  extremely  small 
quantities  of  urine  are  passed,  owing  apparently  to  a  suspension  of 
the  functions  of  the  kidney.  Such  cases  should  always  be  care- 
fully investigated,  to  see  that  the  patient  does  not  deceive  her  at- 
tendants in  regard  to  the  amount  of  urine  passed. 


498  DISEASES   OF   THE    NEKVOUS   SYSTEM. 

Vasomotor  symptoms  are  very  common.  They  consist  of  flush- 
ings and  pallor,  cold  extremities,  and  at  times  an  oedematous  con- 
dition of  one  or  more  extremities.  This  oedema  may  be  of  the 
ordinary  pale,  waxy  character,  pitting  upon  pressure.  In  other 
cases  it  has  a  peculiar  bluish  tinge  and  it  does  not  pit ;  the  hands, 
which  are  the  parts  generally  affected,  are  several  degrees  below 
the  normal  in  temperature,  and  the  limb  resembles  in  some  re- 
spects the  condition  in  Raynaud's  disease.  Gangrene,  however, 
never  supervenes.  This  form  of  oedema  is  known  as  the  blue  oedema 
of  hysteria. 

There  occur  in  hysteria  febrile  attacks,  and  much  has  been 
written  upon  the  subject  of  hysterical  fever.  These  so-called  hys- 
terical pyrexias  may  resemble  in  their  course  typhoid  or  malarial 
fever;  as  a  rule,  the  temperature  runs  a  very  irregular  course,  and 
the  fever  often  lasts  for  weeks  or  even  months.  The  essentially 
neurotic  origin  of  these  fevers  has  hardly  yet  been  established,  and 
one  can  reach  the  diagnosis  only  by  most  carefully  excluding  all 
other  possible  causes. 

AnEemia  is  a  very  common  condition  in  hysterical  patients. 

Hystero- Epilepsy. — The  form  of  hysteria  which  shows  itself  by 
the  development  of  severe  crises  known  as  hystero-epileptic  attacks 
is  extremely  rare  in  this  country,  at  least  in  its  typical  phase.  It 
has  been  particularly  studied  by  the  French  writers  Charcot, 
Richer,  and  others.  Hystero-epilepsy,  as  this  form  of  the  dis- 
ease is  called,  is  a  true  hysteria  and  not  epilepsy  at  all,  nor  a  mix- 
ture of  hysteria  and  epilepsy,  though  the  name  would  suggest  that 
that  was  the  case.  The  typical  attacks  of  hystero-epilepsy  begin 
with  certain  prodromata  consisting  of  a  feeling  of  malaise  and  irri- 
tability which  may  last  for  several  hours  or  a  day.  The  attack  is 
ushered  in  often  with  an  aura,  the  patient  utters  a  cry,  falls  to  the 
ground,  loses  consciousness,  and  enters  into  the  first  phase,  known 
as  the  epileptoid  stage.  During  this  she  suffers  from  tonic  and 
clonic  spasms  very  much  like  those  of  true  epilepsy.  The  muscles 
finally  relax,  and  the  patient  becomes  comatose  for  a  moment  and 
then  enters  the  second  stage,  that  of  the  contortions  and  grand 
movements.  In  this  there  is  opisthotonos,  the  body  is  arched  up, 
and  there  are  violent  movements  of  the  trunk  and  limbs,  which 
undergo  flexion  and  extension,  the  movements  being  all  of  large 
range.  The  next  stage  is  that  of  emotional  attitudes,  during  which 
the  patient  seems  to  be  experiencing  intense  feelings  of  anger,  joy, 
or  some  other  violent  passion,  which  she  expresses  by  the  postures 
of  her  body,  the  movements  of  the  eyes  and  facial  muscles.  This 
stage  over,  she  enters  into  the  last  phase,  which  is  known  as  that 


HYSTERIA. 


499 


of  delirium,  during  which  there  is  a  great  deal  of  mental  excite- 
ment of  a  depressing  character,  from  which  she  gradually  emerges 
into  her  normal  condition.  To  recapitulate :  we  have  in  a  typical 
attack,  first,  prodromata;  second,  the  epileptoid  phase,  lasting 
from  one  to  three  minutes;  third,  the  phase  of  contortions  and 
grand  movements,  one  to  three  minutes;  fourth,  the  emotional 
phase,  lasting  from  five  to  fifteen  minutes ;  and,  finally,  the  stage 


■WlBWito^  "l""»<""««"'';T<rT"""' 

£  Grand  Movements 


3  Passional  4  JJcliricus 


Fig.    225.  —Showing  the  Different  Stages   of  a  Hystero-Epileptic  Seizure   (after 

Richer). 

of  delirium,  lasting  a  variable  time;  the  whole  attack  lasting  from 
five  to  twenty  minutes  (Fig.  225).  In  this  country  we  occasion- 
ally see  hysterical  patients  exhibiting  one  or  two  of  these  phases, 
but  very  rarely  indeed  do  they  ever  go  through  the  whole  series. 
The  patients  who  suffer  from  hystero-epileptic  attacks  generally 
during  the  interparoxysmal  stage  present  many  of  the  stigmata  of 
hysteria,  such  as  paralyses,  contractures,  and  anaesthesias. 

Hysterical  crises  which  take,  the  form  of  convulsions  or  emo- 
tional seizures  sometimes  end  or  are  associated  with  attacks  of 
catalepsy  or  trance  or  attacks  of  amnesia  and  cerebral  automatism. 


500  DISEASES    OF   THE    NERVOUS    SYSTEM. 

As  these  conditions  all  occur  in  other  diseases  than  hysteria,  they 
will  be  described  elsewhere  in  connection  with  the  subject  of  the 
disorders  of  sleep  and  of  consciousness. 

Hysterical  persons  occasionally  are  attacked  with  violent  and 
persistent  hiccoughing  or  sneezing.  Sometimes  also  there  come  on 
attacks  of  extremely  rapid  breathing  or  hysterical  polypncea,  during 
which  the  respirations  run  up  to  fifty  or  seventy  a  minute.  A 
hysterical  cough  sometimes  occurs;  it  lasts  for  a  longtime.  (Eso- 
phageal spasm  with  consequent  dysphagia  is  another  one  of  the 
somewhat  rare  phenomena  of  hysteria. 

Pathology. — There  is  no  known  anatomical  change  at  the  basis 
of  hysteria.  We  do  not  find  the  marks  of  degeneration  as  we  do 
in  certain  forms  of  insanity  and  epilepsy. 

Diagnosis. — Physicians  recognize  three  different  phases  of  hys- 
teria— a  hysterical  temperament,  hysteria  minor,  and  hysteria 
major.  The  hysterical  temperament  is  something  with  which  all 
women  and  many  men  are  naturally  endowed.  It  is  a  condition, 
not  a  disease,  and  does  not  call  for  description  or  elucidation  here. 
Hysteria  minor  is  the  hysterical  temperament  plus  certain  stigmata 
and  the  crises.  One  should  not  make  the  diagnosis  of  hysteria 
minor  unless  he  can  find  these  factors.  The  stigmata  we  have 
already  enumerated,  also  the  peculiar  and  varied  forms  in  which 
the  crises  show  themselves.  In  hysteria  major  we  have  a  much 
greater  preponderance  of  the  stigmata  and  much  severer  forms  of 
the  crises,  these  being  largely  of  a  motor  type.  Hysteria  simu- 
lates many  organic  diseases,  and  it  is  often  difficult  to  distinguish 
surely  the  real  from  the  spurious  thing.  The  essential  character- 
istics of  hysterical  forms  of  disease  are  the  peculiar  emotional  con- 
dition of  the  patient,  the  past  history  of  hysterical  crises,  the  pres- 
ence of  the  stigmata  of  hysteria  such  as  anaesthesias,  limitation  of 
the  visual  field,  paralyses,  and  contractures.  The  variability  of 
the  symptoms,  their  susceptibility  to  influence  under  suggestion 
and  rigorous  moral  measures,  the  absence  of  serious  disturbance  of 
nutrition,  the  sex  and  age,  and  the  cause  should  also  have  weight 
in  guiding  us  to  our  decision. 

Diagnosis  of  special  forms  of  hysterical  manifestations.  Hys- 
terical paralysis  is  characterized  by  the  fact  that  there  is  no  marked 
degree  of  wasting  of  the  muscles,  no  electrical  reactions  of  degene- 
ration, the  deep  reflexes  are  preserved  or  exaggerated,  and  other 
marks  of  hysteria  are  present.  Hysterical  anaesthesia  can  gener- 
ally be  lessened  over  certain  areas  by  the  application  of  the  mag- 
net or  can  be  made  temporarily  to  disappear;  it  is  peculiarly  dis- 
tributed in  the  way  described  under  symptoms  and  is  associated 


HYSTERIA.  501 

with  anaesthesias  of  the  special  senses.  Hysterical  contractures 
sometimes  cease  during  sleep  and  always  under  deep  narcosis,  and 
the  use  of  an  anaesthetic  may  clear  up  the  case.  They  usually 
follow  a  fit,  an  injury,  cr  an  operation.  They  are  somewhat  in- 
creased on  attempts  to  overcome  them  by  force;  they  are  usually 
associated  with  paralysis  and  anaesthesia  and  other  hysterical 
symptoms. 

Hysterical  convulsions.     These  differ  from  convulsions  of  epi- 
lepsy in  the  way  best  indicated  by  the  following  table : 

Hysterical  Convulsion.  Epileptic  Convulsion. 

Brought  on  by  emotion  or  injury  ;  no  The  opposite  in  all  these  particulars, 
aura  ;  no  initial  cry  ;  movements 
co-ordinate  ;  tongue  not  bitten,  and 
patient  never  injures  herself.  Dur- 
ation perhaps  several  hours  with 
intermissions;  consciousness  gen- 
erally preserved.  Micturition  and 
defecation  do  not  occur.  No  rise 
of  temperature ;  may  be  stopped 
artificially. 

The  hystero-epileptic  attacks  are  so  characteristic  that  a  mis- 
take could  not  be  made. 

Prognosis. — The  prognosis  of  hysteria  in  children  is  good. 
They  generally  get  well,  though  in  some  cases  there  is  a  recur- 
rence later  in  life.  In  hysteria  minor  of  young  adults  the  prog- 
nosis varies  with  the  severity  of  the  disease  and  with  the  physical 
strength,  mental  endowment,  and  social  environment  of  the  patient. 
Mild  forms  of  hysteria  under  proper  treatment  usually  get  well. 
The  severer  forms  are  often  intractable  even  under  the  best  treat- 
ment. When  a  severe  form  of  hysteria  occurs  in  a  person  oi 
ble  frame  who  is  surrounded  with  a  sympathetic  family,  the  task 
of  rescuing  her  from  her  disorder  is  a  very  arduous  one.  Trau- 
matic forms  of  hysteria  which  are  not  infrequently  associated  with 
some  actual  physical  injury  are  sometimes  difficult  to  cure.  Hys- 
teria which  is  associated  with  some  organic  disease,  such  as  a  severe 
pelvic  disorder  or  an  organic  affection  of  the  central  nervous  sys- 
tem, has  a  bad  prognosis.  Hysteria  in  the  male  is  generally  cur- 
able, but  it  requires  vigorous  treatment,  and  spontaneous  cure  is 
by  no  means  likely  to  happen. 

Treatment.      The  treatment  of  hysteria  may  be  divided  into  the 
mental,  mechanical,  dietetic,  and  medicinal. 

By  all  odds  the  most  important  factor  in  the  treatment  of  hys- 
teria is  the  mental  treatment,  and  the  most  important  measure  to 


502  DISEASES   OF   THE    NERVOUS   SYSTEM. 

be  taken  is  the  isolation  of  the  patient.  She  should  be  placed 
where  she  will  not  be  surrounded  by  sympathetic  friends;  where 
her  life  will  be  a  regular  one ;  where  some  occupation  may  be  given 
which  will  engross  her  attention,  interest  her  mind,  and  call  into 
play  her  physical  activities.  In  the  major  forms  of  hysteria  asso- 
ciated with  anorexia,  emaciation,  anaemia,  and  possibly  pelvic  dis- 
orders, the  "  rest  cure"  as  elaborated  and  carried  out  by  Weir 
Mitchell  forms  by  all  odds  the  most  successful  means  of  treatment. 
In  many  cases  of  less  severe  character  a  partial  rest  cure  in  which 
the  patient  is  separated  from  her  family  but  is  not  placed  under 
such  severe  restrictions  may  be  all  that  is  needed.  In  the  case  of 
children  removal  from  home  is  often  advisable,  and  the  discipline 
of  well-conducted  schools  is  a  most  excellent  measure. 

The  mechanical  means  used  in  hysteria  are  hydrotherapy,  elec- 
tricity, massage,  and  exercise.  Of  these  measures  hydrotheraphy 
and  electricity  take  the  first  rank.  In  hydrotherapy  the  douche 
or  jet  to  the  back,  the  shower  and  cold  plunge,  and  the  half -bath 
are  the  most  efficacious.  The  technique  of  their  use  is  given  else- 
where. In  the  electrical  treatment  the  static  and  faraclic  currents 
give  the  best  results.  The  static  sparks  often  relieve  contractures 
and  lessen  or  remove  the  anaesthesias,  and  both  forms  of  electricity 
seem  to  have  a  generally  beneficial  tonic  effect.  Massage  is  of 
some  value  in  promoting  nutrition  and  it  also  has  a  favorable  seda- 
tive effect  on  many  cases.  Exercise,  particularly  of  an  active  kind 
such  as  stimulates  the  mind  and  interests  one,  is  a  measure  of  ex- 
treme value  and  one  which  has  perhaps  not  been  sufficiently  appre- 
ciated. The  use  of  the  bicycle,  playing  tennis,  and  horseback- 
riding  are  measures  which  cannot  be  too  strongly  recommended  to 
hysterical  women ;  in  fact,  it  is  probable  that  some  cases  which  are 
submitted  to  the  rest-cure  treatment  might  do  better  by  an  entirely 
opposite  kind  of  procedure. 

The  drugs  which  can  be  recommended  in  hysteria  are  not  nu- 
merous and  their  power  is  limited.  Valerianate  of  zinc,  turpentine, 
asafoetida,  tincture  of  sumbul,  iron,  and  the  bromides  are  the  most 
important  of  the  nervines.  In  hysterical  children  a  capsule  con- 
taining two  grains  of  valerianate  of  zinc  and  one  of  sulphate  of  qui- 
nine is  often  efficacious.  Gowers  places  more  reliance  upon  the  oil 
of  turpentine  in  doses  which  should  be  increased  to  the  point  of 
strangury.  Pitres  recommends  the  wearing  of  colored  glasses  in 
order  to  keep  off  hysterical  attacks.  Some  experimentation  is 
necessary  in  order  to  see  which  color  is  most  suited  to  the  case. 

In  the  treatment  of  hysterical  convulsions  the  most  efficient 
measure  is  the  administration  of  an  emetic,  and  this  can  be  best 


HYSTERIA.  503 

done  by  giving  hypodermically  one-twelfth  of  a  grain  of  aponior- 
phine.  Convulsions  can  be  stopped  sometimes  by  throwing  water 
in  the  face  or  on  the  epigastrium;  by  firm  and  somewhat  long- 
continued  pressure  over  the  ovaries ;  by  the  administration  of  vale- 
rian, aromatic  spirits  of  ammonia,  or  compound  spirits  of  ether. 

The  Spasmodic  Tics   (Tio  Coxvulsif). 

Spasmodic  tic  is  a  disease  to  which  the  name  of  chorea  is  often, 
but  incorrectly,  given.  It  is  a  very  chronic  disorder,  and  shows 
itself  in  the  form  of  quick,  electric-like  spasms  of  certain  groups 
of  muscles  or  single  muscles.  The  spasmodic  movements  are  violent, 
and  several  rapid  contractions  succeed  each  other,  after  which  there  is 
a  period  of  rest.  The  spasm  has  a  tendency  to  become  localized  in 
certain  nerves,  especially  the  facial  (mimic  tic),  or  even  in  a  single 
branch  or  twig,  as  that  to  the  orbicularis,  the  zygomaticns,  the  dia- 
phragm,  or  the  tensor  tympani.  Spasmodic  tic  sometimes  involves 
the  muscles  of  expiration  and  the  larynx,  and  then  it  has  been 
wrongly  called  chorea  of  the  larynx.      Stuttering  is  a  form  of  tie. 

The  convulsive  movements  may  take  a  wide  range  and  affect 
a  number  of  groups  cf  muscles,  producing  quick,  violent  move- 
ments of  the  body.  They  are  sometimes  accompanied  by  explo- 
sive disturbances  of  speech.  In  these  cases  the  patient  at  the  time 
of  the  convulsive  movement  utters  some  obscene  or  profane  words 
(coprolalia),  or  involuntarily  repeats  the  last  words  of  the  sentence 
spoken  to  him  (echolalia),  or  spasmodically  imitates  a  gesture  made 
to  him  {eehokinesis),  or  involuntarily  exclaims  the  thought  upper- 
most in  his  mind,  perhaps  revealing  some  secret  against  his  will 
(tic  de pensee). 

The  peculiar  disorder  of  the  Maine  "jumpers,"  characterized 
by  sudden  violent  movements  on  being  touched  or  startled,  is  a 
form  of  tic.  So  also  are  the  similar  troubles  known  as  lotah,  oc- 
curring in  Malay,  and  myriachit,  occurring  in  Siberia  and  Kam- 
chatka. 

Most  of  the  special  forms  of  spasmodic  tic  (mimic  tic,  wryneck, 
etc.)  have  been  described  elsewhere. 

Spasmodic  fi<-  with  coprolalia  affects  children  between  the  ages 
of  six  and  sixteen  years,  and  by  preference  the  masculine  sex. 
There  is  almost  always  a  neurotic  family  history,  and  the  children 
are  nervous. 

The  disease  begins  with  attacks  of  violent  and  irregular  move- 
ments, affecting  generally  the  head,  face,  and  upper  extremities 
first,  then  involving  the  whole  body.     The  movements  can  be  con- 


504  DISEASES    OF    THE    NERVOUS    SYSTEM. 

trolled  tor  a  time  by  the  will,  only  to  break  out  with  increased 
violence  later.  They  cease  entirely  during  sleep,  which  is  gener- 
ally profound. 

After  having  suffered  from  the  disease  for  a  time,  the  patient 
will,  with  the  attacks,  utter  inarticulate  cries,  or  he  may  begin  to 
repeat  or  echo  the  words  that  he  overhears.  All  this  is  done  auto- 
matically and  suddenly,  with  the  accompaniment  of  grimaces  and 
muscular  contortions.  The  special  peculiarity  of  the  disease  is  the 
sudden  interjection  by  the  patient  of  obscene  words  and  expressions 
(coprolalia) . 

The  disorder  is  chronic,  lasting  for  years.  It  is  best  treated  by 
isolation,  tonics,  and  ordinary  antispasmodics. 

Thomsen's  Disease  (Myotonia  Congenita). 

This  is  a  hereditary  family  disease  characterized  by  the  devel- 
opment of  tonic  cramps  when  the  patient  attempts  voluntary  move- 
ments.    The  disorder  is  very  rare. 

Etiology.  — Congenital  myotony  is  practically  always  hereditary 
aud  runs  in  families.  It  affects  males  by  preference  and  develops 
at  the  time  of  adolescence. 

Symptoms. — The  patient  notices  that  on  trying  to  rise  or  walk 
his  legs  are  seized  with  a  painless  cramp,  which  in  a  few  seconds 
relaxes,  but  comes  on  again  when  the  muscular  movements  have 
been  repeated.  If  he  closes  his  hands  tightly  a  cramp  occurs  and 
he  cannot  relax  the  grip.  If  he  shuts  his  eyes  he  cannot  open 
them  for  a  moment.  The  muscles  of  mastication  may  be  affected, 
but  the  extremities  are  the  parts  most  involved.  The  involuntary 
muscles  are  spared.  The  cramps  are  increased  by  cold  and  ner- 
vousness; they  are  lessened  by  muscular  exercise.  The  muscles 
are  somewhat  hypertrophied,  and  the  patient  may  present  the  ap- 
pearance of  a  very  strong  man.  The  actual  strength  is  fair,  but 
less  than  would  seem.  The  general  health  may  be  good,  but  the 
patients  sometimes  show  the  signs  of  low  vitality  in  weak  diges- 
tion, feeble  sexual  power,  and  susceptibility  to  cold. 

The  electrical  excitability  of  the  nerves  is  normal,  that  of  the 
muscles  is  increased,  and  there  is  produced  a  contraction  tetanus 
by  both  currents.  In  addition  Erb  describes  a  peculiar  reaction 
produced  by  a  strong  stabile  galvanic  current.  It  consists  in  the 
appearance  of  wave-like  muscular  movements  passing  from  cathode 
to  anode.  This  was  not  present  in  my  case  or  Jacoby's.  The 
mechanical  excitability  of  the  mm  cles  is  also  increased. 

Pathology. — The  disease  is  p/obably  a  primary  muscular  dys 
trophy.     There  may  be,  however,  a  peculiar  defect  in  innervation, 
resulting   from  a  congenital   anomaly  of  the  motor  tracts.     The 
muscular  fibres  are  found  to  be  hypertrophied,  the  striations  indis- 
tinct, and  the  nuclei  increased. 


HYSTERIA.  505 

The  diagnosis  is  easily  made  by  the  characteristic  tonic  cramps. 

The  prognosis  is  bad  as  regards  cure,  but  the  disorder  does  no*", 
shorten  life. 

Treatment. — Dr.  Thoinsen,  who  first  described  the  disease, 
states  that  active  muscular  exercise  benefits  patients.  No  specific 
measures  are  known. 

Congenital  Paramyotonia. 

Paramyotonia  is  the  name  given  to  a  form  of  myotonia  in  which 
the  symptoms  deviate  somewhat  from  the  typical  ones  that  appear 
in  Thomsen's  disease.  Paramyotonia  occurs  symptomatically,  con- 
genially, and  in  a  peculiar  clinical  form  known  as  ataxic.  We 
have,  therefore,  symptomatic,  congenital,  and  ataxic  forms. 

Symptomatic  paramyotonia  is  noted  most  characteristically  in 
a  certain  form  of  paralysis  agitans.  Here  the  patient,  when  at- 
tempting to  walk  or  to  rise  from  the  sitting  posture,  is  suddenly 
seized  with  an  apparent  rigidity  of  the  muscles  which  prevents  him 
from  stirring.  The  myotonic  condition  appears  also  in  spastic 
paralyses  of  spinal  and  cerebral  origin. 

Congenital  paramyotonia  is  a  family  affection,  resembling  in  this 
respect  Thomsen's  disease.  The  muscular  rigidity  is  brought  on 
not  by  voluntary  movements,  but  by  exposure  to  cold  and  often 
very  slight  degrees  of  cold.  The  tonic  spasm  is  a  long  one  and 
Lists  for  from  a  quarter  of  an  hour  to  several  hours.  It  affects 
the  arms  move  than  the  legs.  The  facial  muscles  are  prone  to  be- 
come rigid.  The  attacks  are  followed  by  some  muscular  weakness. 
In  congenital  paramyotonia  the  trouble  is  undoubtedly  a  primary 
disturbance  of  the  muscles;  in  other  words,  a  myopathy. 

Ataxic  paramyotonia  is  the  name  given  to  a  disorder  character- 
ized by  transient  spasms  like  those  of  Thomsen's  disease,  associ- 
ated with  distinct  ataxia  and  also  with  weakness  and  some  anaesthe- 
sia (Gowers).  This  disease  is  probably  located  in  the  spinal  cord 
and  should  perhaps  be  considered  one  of  the  forms  of  symptomatic 
paramyotonia.  Xo  special  treatment  can  be  given  for  either  of 
the  two  latter  forms  of  disease,  of  which  very  few  examples  have 
been  observed. 

Akinesia  Algera  (Pain  Palsy). 

Akinesia  algera  is  the  name  given  by  Moebius  to  a  peculiar  form 
of  paralysis  which  occurs  in  psychopathic  persons  and  is  due  li>  the 
fact  that  intense  pains  are  produced  by  every  muscular  movement. 
The  result  is  that  the  patient  lies  helplessly  in  bed,  afraid  to  stir 
hand  or  foot.  The  disease  occurs  only  in  prisons  who  have  a  very 
unstable  nervous  system  and  generally  m  those  who  have  a  para- 
noiac tendency.  It  occurs  in  adults  only.  Pain  paralysis  (ones 
on  gradually  and  affects  eventually  all  the  muscles  of  the  extremi- 
ties and  body.  There  are  no  objective  disturbances  such  as  atro- 
phy, electrical  degenerations,  and  anaesthesias.  The  muscles  and 
skin,   however,    are  somewhat  tender  to  the  touch.     The   disease 


506  DISEASES    OF   THE    NEEVOUS    SYSTEM. 

lasts  a  long  time.  The  patient  sometimes  improves,  in  other  cases 
insanity  ensues.  The  disease  is  essentially  a  form  of  insanity,  a 
pathophobia,  and  is  allied  to  the  disorder  known  as  mysophobia. 
The  paralysis  is  the  result  of  pain  hallucination,  and  the  patient  is 
afraid  to  move  the  arm  or  leg  on  acccount  of  this  hallucination,  just 
as  the  mysophobic  patient  is  afraid  to  touch  anything  on  account  of 
the  fear  of  contamination. 

The  prognosis  is  bad,  and  so  far  treatment  has  accomplished 
little  or  nothing. 


CHAPTER  XXIV. 

THE  ACQUIRED  LEUKOSES. 

Chorea   (St.  Vitus'   Dance). 

Under  this  name  various  spasmodic  disorders  have  been 
described.     They  are  to  be  classed  as  follows : 

I.  Common  chorea,  or  Sydenham's  chorea. 

II.  Hereditary  chorea,  or  Huntington's  chorea. 

III.  The  convulsive  tics. 

IV.  Hysterical  chorea,  including  so-called  chorea  major. 

V.  Various  local  endemic  choreas,  such  as  the  electric  chorea  of 
Dubini  and  the  electric  chorea  of  Bergeron. 

Chorea  of  Sydenham. 

This  is  the  common  type  of  chorea,  and  is  the  disease  ordinarily 
meant  when  the  term  chorea  is  used.  It  is  a  subacute  disorder 
characterized  by  irregular  jerking  and  inco-ordinate  movements. 
The  disease  is  a  common  one,  forming  about  one-fifth  of  the  nervous 
diseases  of  children. 

Etiology. — Most  cases  occur  between  the  ages  of  five  and  fifteen 
(see  chart,  p.  476).  It  is  very  rare  under  five.  A  few  cases  occur 
after  twenty,  and  even  up  to  old  age,  when  a  senile  chorea  is  some- 
times observed.  It  affects  girls  more  than  boys  in  the  ratio  of 
about  2.5  to  1.     In  adult  life  the  disproportion  is  less  marked. 

It  is  relatively  rare  in  the  negro  race,  especially  in  those  of  pure 
blood  (Mitchell).  In  this  country  it  is  more  common  in  children  of 
German,  Hebrew,  and  Portuguese  races. 

It  occurs  in  all  climates.  Most  cases  develop  in  the  spring 
months,  next  in  the  autumn,  next  in  winter,  and  last  in  summer. 
The  seasonal  influence  varies  in  different  localities.  In  Philadel- 
phia more  cases  occur  relatively  in  the  spring.  In  New  York  there 
is  an  almost  equal  increase  in  the  autumn.  School  attendance  has 
something  to  do  with  these  variations.  Choreic  attacks  appear  to 
be  related  to  increase  in  storms  (Lewis).  The  disease  is  more  fre- 
quent in  cities,  and  probably  in  the  poorer  classes.  Hereditary  in- 
fluence is  slight,  but  it  exists.     In  a  small  percentage  of  cases  one 


508  DISEASES   OF   THE   NERVOUS   SYSTEM. 

parent  has  had  chorea,  epilepsy,  insanity,  or  a  decided  neuropathic 
constitution.  A  phthisical  or  a  gouty  history  in  parents  is  also  not 
rare. 

The  chief  exciting  causes  are  injury  and  fright,  mental  worry, 
and  rheumatism.  Fright  or  some  emotional  disturbance  is  a  cause 
in  about  one-fifth  of  the  cases.  Acute  rheumatism  is  given  as  a 
cause  in  very  varying  proportions,  ranging  from  five  to  twenty-five 
per  cent.  In  this  country  it  ranges  from  fifteen  to  twenty  per  cent 
(Sinkler,  Starr,  Sachs,  and  personal  observations).  Endocarditis  is 
developed  in  the  course  of  chorea  in  a  slightly  larger  proportion  of 
cases.  This  may  exist  without  any  manifestations  of  rheumatism. 
Pregnancy  is  a  cause  of  chorea  generally  in  primiparse  and  always  in 
young  w  mien  under  twenty  -five.  Chorea  sometimes  follows  infec- 
tious fevers,  especially  measles,  scarlatina,  and  whooping-cough. 
It  has  been  caused  in  rare  cases  by  reflex  irritation  from  an  injury, 
from  nasal  disease,  and  from  sexual  disorders.  Overstudy  and  the 
worry  of  examinations  are  factors  in  causing  chorea  in  predisposed 
and  badly  nourished  children.  Intestinal  irritations,  such  as  worms, 
may  excite  chorea.  Malaria  also  may  aggravate,  if  it  does  not  pro- 
duce it.  Hamilton  describes  a  form  of  chorea  caused  by  tobacco- 
poisoning.     Anaemia  and  malnutrition  underlie  most  cases. 

Symptoms. — The  disease  may  begin  suddenly,  but  usually  it  de- 
velops slowly,  and  it  is  not  till  one  or  two  weeks  that  the  symptoms 
are  decidedly  prominent.  It  usually  begins  with  irregular  twitch- 
ing of  the  hand  or  face  on  one  side.  The  child  winks,  grimaces, 
and  drops  things  from  its  hand.  The  foot  and  leg  become  affected 
later  and  the  child  stumbles  in  walking.  In  two  or  three  weeks  the 
opposite  side  is  involved,  but  usually  less  than  the  one  originally 
affected.  In  three  or  four  weeks  the  disease  reaches  its  height. 
The  patient's  movements  are  then  almost  continuous.  The  hands 
can  hardly  be  used  and  the  child  has  to  be  fed  and  dressed;  even 
walking  is  awkward  and  difficult.  Speech  is  indistinct  and  confused 
from  the  irregular  movements  of  the  lips  and  tongue.  The  muscles 
of  respiration  may  be  involved  so  that  the  rhythm  is  uneven.  It  is 
asserted  that  the  heart's  action  is  affected  also;  but  this  is  unlikely. 

The  choreic  movements  usually  occur  both  when  the  muscles  are 
at  rest  and  during  volitional  acts.  In  some  cases  the  disease  is 
chiefly  characterized  by  inco-ordinate  movements  when  purposeful 
acts  are  attempted.  In  other  cases  voluntary  movements  can  be 
readily  performed,  and  the  muscles  twitch  only  when  the  limbs  are 
at  rest.  The  movements  cease,  as  a  ride,  during  sleep.  But  the 
child  sometimes  sleeps  badly  on  account  of  the  movements.  In  se- 
vere eases  attacks  of  mental  excitement  and  even  delirium  come  on 


THE    ACQUIRED    NEUROSES.  509 

for  several  successive  nights,  and  this  may  be  so  marked  a  feature 
as  to  form  what  is  called  chorea  insaniens,  or  maniacal  chorea. 
Apart  from  such  phenomena,  the  mind  in  chorea  is  usually  dulled, 
the  temper  irritable,  and  the  child  much  harder  to  manage. 

The  appetite  is  poor  and  capricious,  the  tongue  coated,  and  the 
bowels  are  often  constipated.  The  nutrition  fails  a  little ;  there  are 
antenna  and  a  tendency  to  loss  of  flesh. 

The  eyes  present  nothing  abnormal.  Hypermetropia,  astig- 
matism, and  muscular  insufficiencies  exist,  but  not  much  more  than 
in  other  nervous  children. 

The  child  is  often  worse  in  the  morning  and  improves  toward 
night.  Excitement  and  physical  exertion  make  the  movements 
worse.  There  is  rarely  any  pain  and  never  anaesthesia  or  tender- 
ness. The  muscles  are  weak  but  not  actually  paralyzed.  The  deep 
reflexes  are  somewhat  lessened  and  the  knee  jerk  may  be  abolished. 
The  electrical  irritability  of  the  muscles  is,  as  a  rule,  increased,  but 
there  are  no  qualitative  changes.  Nocturnal  enuresis  occasionally 
occurs.  The  urine  contains  an  excess  of  urea  and  phosphates,  and 
at  the  height  of  the  attack  the  specific  gravity  may  be  increased. 

Forms. — Maniacal  chorea  is  characterized  by  great  mental  ex- 
citement— especially  at  night,  delirium,  with  hallucinations  and  de- 
lusions. After  one  or  two  weeks  the  excitement  lessens  and  the  pa- 
tient becomes  dull  and  apathetic.  Such  cases  usually  occur  in  adult 
women,  and  they  are  sometimes  fatal. 

Paralytic  chorea.  In  this  form  one  arm  becomes  rather  suddenly 
weak  and  powerless.  A  few  twitching  movements  are  observed. 
This  form  occurs  only  in  children  and  runs  the  same  course  as  the 
spasmodic  type. 

Chorea  of  adult  life  and  senile  chorea.  The  disease  when  it  oc- 
curs in  the  second  half  of  life  attacks  men  rather  oftener  than  wo- 
men ;  it  is  not  related  to  rheumatism.  There  is  usually  a  neurotic 
family  history  and  even  a  hereditary  history  of  chorea.  The  attack 
is  usually  caused  by  emotional  disturbances.  It  runs  much  the  same 
course  as  juvenile  chorea,  but  it  rather  more  apt  to  become  chronic. 
When  it  occurs  in  old  men  it  is  called  senile  chorea.  This  type  is 
not  to  be  confounded  with  hereditary  or  Huntington's  chorea. 

J  hi  ml  inn — Relapies. — The  disease  in  this  country  lasts  about 
ten  or  twelve  weeks,  ranging,  however,  from  six  weeks  to  six 
months.  There  may  be  great  improvement  followed  by  a  relapse, 
and  in  this  remittent  manner  the  disease  may  last  for  years.  If  it 
last  more  than  six  months  it  should  be  called  chronic.  Relapses 
occur  in  about  one-third  of  the  cases  and  rather  oftener  in  girls. 
Relapses  occur  oftenest  within  a  year  of  the  first  attack  and  much 


510 


DISEASES   OF   THE   NEKVOUS   SYSTEM. 


oftener  in  the  spring.  After  three  years  relapses  practically  cease. 
The  number  of  relapses  is  usually  but  one,  but  the  disease  may  recur 
eight  or  niue  times.  Relapses  rarely  occur  in  adults  except  in  the 
chorea  of  pregnancy. 

Pathology.— The  seat  of  the  lesions  in  chorea  is  the  gray  matter 
of  the  cortex  and  its  meninges,  the  pyramidal  tract,  basal  gan- 
glia, and  the  spinal  cord.     The  lesions  are  in  acute  cases  of  the 


Fig.  226. — Perivascular  Dilatations  in  the  White  Matter  of  the  Convolutions  of  a 
Very  Chronic  and  Severe  Case  of  Chorea. 


nature  of  intense  hyperemia,  with  dilatation  of  vessels,  small  hem- 
orrhages, and  spots  of  softening.  There  are  infiltration  of  the  peri- 
vascular spaces  with  round  cells  and  swelling  and  proliferation  of 
the  intima  of  the  small  arteries.  In  chronic  cases  the  evidence  of 
active  vascular  irritation  is  less,  but  there  are  perivascular  dilata- 
tions and  increase  of  connective  tissue  (Fig.  226).  The  process 
suggests  a  low  grade  or  an  initial  stage  of  inflammation.  The 
cause  of  this  is  probably  either  an  infective  micro-organism  or  a 
humoral  irritation  similar  to  that  causing  the  rheumatic  symptoms 


THE    ACQUIKED   NEUROSES.  511 

and  the  heart  lesions.  In  a  considerable  per  cent  of  cases  (ninety 
per  cent — Osier),  especially  in  those  of  long  duration,  there  are 
fibrinous  deposits  on  the  walls  of  the  heart.  The  hyperseniic  proc- 
ess may  not  be  confined  to  the  meninges  and  motor  areas  of  the 
brain  and  cord,  but  it  is  only  from  the  disease  in  these  parts  that 
the  symptoms  of  chorea  arise.  The  presence  of  points  of  irritation 
in  the  cortex  and  its  meninges  and  in  the  deeper  parts  excites  irreg- 
ular discharges  of  nerve  force  and  produces  the  choreic  movements. 
The  interruption  of  the  voluntary  nerve  impulses  by  diseased  foci 
makes  these  movements  irregular.  The  apparently  special  involve- 
ment of  the  lenticular  nuclei  may  explain  some  of  the  inco-ordina- 
tion.  In  paralytic  chorea  the  pyramidal  tract  is  probably  more  se- 
riously injured  by  some  single  large  focus  of  congestion,  exudation, 
or  hemorrhage.  Indeed,  I  have  seen  a  true  hemiplegia  develop  in 
the  midst  of  an  attack.  In  maniacal  chorea  the  meninges  and  cortex 
are  more  involved. 

Diagnosis. — The  disease  is  easily  recognized  by  the  peculiar 
twitching  movements.  It  is  necessary  only  to  distinguish  the  dif- 
ferent forms.  It  must  be  distinguished  from  convulsive  tic,  electric 
chorea  of  Dubini,  hysterical  spasms  which  include  myoclonus,  sal- 
tatory chorea,  and  chorea  major.  The  distinctions  are  not  difficult 
and  are  given  in  connection  with  the  descriptions  of  these  disorders. 

Prognosis. — As  regards  life  the  prognosis  is  very  favorable.  In 
this  country  death  from  chorea  hardly  ever  occurs  in  children.  It 
is  more  fatal  in  adults.  In  England  the  mortality  from  chorea  is 
about  two  per  cent.     Nearly  all  non-fatal  cases  eventually  get  well. 

Treatment. — The  most  important  single  factor  in  treatment  is 
rest.  The  child  should  not  be  allowed  to  take  violent  exercise  or 
to  have  any  excitement.  In  most  cases  he  should  be  taken  from 
school,  and  in  bad  cases  he  should  be  kept  in  bed. 

Cold  sponging  or  the  ether  spray  daily  along  the  back  is  useful. 
Nourishing  food  and  iron  are  indicated. 

As  specific  remedies,  arsenic  still  heads  the  list.  It  should  be 
given  in  doses  of  Hlv.  of  Fowler's  solution  t.i.d.,  increased  by  one 
or  two  drops  daily  to  fifteen  or  twenty  drops  or  even  more.  If  this 
causes  nausea  and  gastric  pain  or  headache,  the  dose  should  be 
stopped  for  a  day  and  then  resumed,  if  possible,  where  it  was  left 
off.  Sometimes  the  sulphide  of  arsenic  is  better  tolerated  than  the 
arsenite.  Next  to  arsenic  come  antipyrin  (gr.  v.),  antifebrin  (gr. 
iij.),  exalgin  (gr.  iij.),  the  doses  to  be  carefully  increased  if  needed. 
Tincture  of  cimicifuga  sometimes  helps  when  arsenic  fails.  The 
bromide  or  valerianate  of  zinc  is  also  an  excellent  remedy,  especially 
when  there  is  a  hysterical  element.     The  bromides  and  chloral  are 


51^  DISEASES   OF   THE   XERYOUS    SYSTEM. 

useful  adjuvants  in  promoting  sleep.  Chloral  alone  is  said  to  be 
curative  if  given  in  doses  sufficient  to  prolong  sleep  greatly  (Bastian). 
Exalgin  given  cautiously  with  iron,  in  doses  increased  to  fifteen  grains 
a  day,  is  often  very  useful.  Hyoscine  hydrobromate  in  doses  of  gr. 
TJF  is  occasionally  efficacious.  Among  other  drugs  of  less  value 
are  the  salicylates,  cypropedium,  lobeline,  physostigmine,  and  tartar 
emetic.  In  chronic  and  obstinate  cases  hypodermic  injections  of 
Eowler's  solution  should  be  tried.  Galvanization  of  the  brain  and 
spine  is  also  useful.     Change  of  air  sometimes  breaks  up  an  attack. 

Hereditary  chorea  was  first  deserved  by  a  Long  Island  phy- 
sician, Dr.  Waters,  in  1842,  later  by  Drs.  Gorman  and  Lyon,  and 
in  1872  by  Dr.  Huntington.  The  American  cases  have  been  ob- 
served chiefly  in  New  York,  Connecticut,  New  Jersey,  and  Penn- 
sylvania. Cases  have  been  reported  also  from  Germany,  France, 
and  England.  The  disease  rarely  begins  before  thirty  or  after 
fifty ;  it  occurs  about  equally  in  males  and  females.  It  is  always 
directly  hereditary,  either  through  father  or  mother,  usually  the 
latter.  It  begins  without  known  cause  by  twitchings  in  the  face; 
the  movements  then  extend  to  the  arms  and  legs.  It  is  attended 
by  progressive  mental  deterioration,  by  a  tendency  to  melan- 
cholia, and  finally  ends  in  dementia.  Its  course  is  chronic  and  usu- 
ally very  slow,  lasting  ten  or  twenty  years.  Post  mortem,  chronic 
pachymeningitis  and  leptomeningitis  with  degenerative  changes  in 
the  cortex  have  been  found. 

Electric  Chorea  is  a  name  sometimes  and  wrongly  given  to 
very  violent  forms  of  ordinary  chorea  of  Sydenham.  The  term  was 
first  applied  by  Dubini  to  a  peculiar  and  progressively  fatal  spas- 
modic affection  which  has  been  observed  almost  solely  in  Italy,  and 
which  is  perhaps  of  a  podagrous  or  malignant  malarial  origin.  M. 
Bergeron  in  1880  also  described  an  "  electric  chorea  "  in  which  the 
patients  are  attacked  by  sudden  rhythmical  spasms.  This  latter 
disease  has  a  uniformly  favorable  course.  Neither  of  these  dis- 
eases resembles  true  chorea,  nor  do  they  have  the  character  of  the 
tics. 

The  term  electric  chorea,  therefore,  is  one  that  should  be  used, 
if  at  all,  only  with  a  qualifying  explanation. 

Habit  Chorea  (Ti<-  Coordine). — There  are  many  persons  who 
go  through  life  with  some  trick  of  speech,  of  gesture,  or  some  pecu- 
liar grimace.  It  may  be  only  a  shrug  of  the  shoulder,  a  twitching 
of  the  eyes,  or  a  sniff.  These  various  movements  are  tics  of  the 
co-ordinate  kind.  The  spasmodic  motion  is  of  itself  normal,  but  is 
inappropriate  and  misapplied. 

Such  movements  are  often  seen  in  children.  They  sometimes 
represent  abortive  attacks  of  chorea,  and  sometimes  they  are  the 
residuum  of  old  attacks.     In  many  cases  they  are  chronic  convul- 


THE   ACQUIRED    NEUROSES.  *  513 

sives  tics  from  the  start  and  have  little  relationship  to  Sydenham's 
chorea.  The  condition  is  to  be  treated  both  by  moral  and  medi- 
cinal measures. 

Oscillatory  spasms  and  nodding  spasms  have  been  described  else- 
where. 

Procursive  Chorea,  or  Dancing  Chorea. — Laycock  has  described 
as  a  separate  kind  of  chorea  a  rhythmical  or  trochaic  form,  which  he 
says  affects  children,  principally  girls,  and  shows  itself  in  spas- 
modic rhythmical  contractions  or  in  sudden  rotating  or  procursive 
movements  of  the  body.  This  has  been  called  chorea  procursive,  or 
chorea  festinans,  by  other  writers.  In  many  cases  it  is  accompanied 
by  vertigo,  when  the  condition  of  the  patient  is  similar  to  that  of 
a  person  who  has  been  whirling  around  a  number  of  times.  Such 
cases  always  have  decidedly  hysterical  characters,  although  these 
procursive  attacks  may  complicate  ordinary  chorea. 

Chorea  major  is  a  manifestation  of  hysteria,  and  has  been  de- 
scribed under  that  head.     It  is  not  a  chorea  at  all. 

PABAMYOCLONU8    MULTIPLEX     (MYOCLONUS    MULTIPLEX,     CONVUL- 
SIVE  Tremor,    Myospasia). 

Myoclonus  multiplex  is  a  rare  disease  allied  in  nature  to  the 
convulsive  tics  and  characterized  by  attacks  of  quick  clonic  spasms 
affecting  the  trunk  and  sometimes  the  extremities  also.     The  dis- 

occurs  most  often  in  adult  males.  It  is  caused  usually  by 
fright,  injury,  or  some  violent  emotion.  A  condition  resembling  it 
is  produced  by  removal  of  the  thyroid.  Very  different  forms  of 
spasm  have  been  described  under  the  name  myoclonus  multiplex, 
but  there  are  two  groups  of  cases  which  may  be  distinguished. 
One  is  of  hysterical  type,  the  other  belongs  to  the  convulsive  tics, 
and  in  its  typical  form  myoclonus  is  to  be  classed  with  this  latter 
form  of  spasmodic  disorder.  In  the  hysterical  form  the  patient 
without  warning  is  seized  with  sudden  and  Lightning-like  contrac- 
tions of  the  trunk  and  hip  i  Luscles,  which  cause  his  body  to  be  al- 
ternately flexed  and  extended  so  violently  that  he  is  often  thrown 
from  the  chair  or  couch  on  which  he  is  lying.  The  arms  and  legs 
may  be  also  involved,  and  the  attack  takes  on  the  characteristics  of 
a  general  tremor  in  which  the  whole  body  shakes.     The  attack  then 

3  ami  the  patient  has  a  rest  for  hours  or  days.  In  the  true 
or  choreiform  type  the  disease  comes  on  more  slowly,  with  sharp 
choreic-like  twitchings,  and  the  patient  presents  something  of  the 
aspect  of  chronic  chorea.  The  facial  muscles  may  be  affected,  but 
not  those  of  the  eyes.  The  spasmodic  movements  are  bilateral, 
although  they  sometimes  begin  on  one  side.  The  convulsions  differ 
from  those  of  hysteria  in  that  they  affed  groups  of  muscles  that 
have  not  the  same  physiological  function  and  produce  movements 
which  cannot  be  easily  imitated  voluntarily.  Still  this  distinction 
is  not  a  sharp  one.  The  patients  are  generally  neurasthenic.  They 
33 


514  DISEASES    OF   THE    NERVOUS   SYSTEM. 

have  no  paralyses,  no  anaesthesias,  very  few  pains,  and  their  bodily 
nutrition  is  not  seriously  impaired. 

The  pathology  and  pathological  anatomy  are  unknown. 

The  diagnosis  is  based  on  the  peculiar  character  of  the  spasm, 
on  the  fact  that  the  trunk  muscles  are  involved,  and  that  the  spasms 
are  bilateral.  The  disease  usually  lasts  but  a  few  months  in  the 
hysterical  form,  but  it  may  extend  over  a  number  of  years. 

The  prognosis  is  fairly  good. 

The  treatment  consists  of  tonics  and  the  use  of  chloral  and  hyos- 
cine.  Galvanism  seems  to  be  very  efficient.  Atropine  and  hyos- 
cine  are  indicated,  and  hydrotherapy  may  also  be  advantageously 
employed.     Thyroid  extract  has  been  of  benefit. 


Saltatory  Spasm. 

This  is  a  curious  and  rare  form  of  disease  characterized  by  con- 
vulsive movements  of  the  legs  brought  out  by  touching  the  feet 
to  the  floor.  It  occurs  in  both  sexes  and  at  all  ages,  but  usually 
in  those  of  a  neurasthenic  and  hysterical  temperament.  The  phe- 
nomena of  the  disease  are  exhibited  when  the  patient  attempts  to 
stand.  The  minute  that  the  feet  touch  the  floor  violent  contractions 
occur  in  the  muscles  of  the  calves  and  hips,  sometimes  in  the  whole 
body ;  these  cause  the  patient  to  jump,  and  the  movements  may  be 
so  severe  as  to  throw  him  down.  The  seizures  are  brought  on  only 
by  the  exciting  effects  of  the  weight  of  the  body  on  the  feet.  Sal- 
tatory spasm  is  probably  a  form  of  hysterical  spasm.  It  has  been 
described  chiefly  by  the  older  writers,  and  its  symptomatology  and 
pathology  have  not  been  carefully  worked  out. 


Tetanus. 

Tetanus  is  an  acute  or  subacute  infectious  disease  characterized 
by  violent  tonic  spasms  with  remissions  and  exacerbations.  It  is 
called  idiopathic  when  no  open  wound  is  found  and  traumatic  when 
such  condition  is  present.  When  it  attacks  infants  it  is  called  tet- 
anus neonatorum;  when  the  jaws  alone  are  involved  it  is  called 
lockjaw,  or  trismus.  A  form  which  affects  the  face  and  throat  is 
called  head  or  cephalic  tetanus. 

Etiology. — It  has  a  special  predilection  for  newborn  children  in 
some  countries  (West  Indies)  and  to  a  less  extent  for  puerperal  wo- 
men. It  affect  males  more  than  females.  After  the  first  month  of 
life  there  is  practical  immunity  till  after  the  tenth  year.  It  then 
increases  in  frequency  up  to  forty.  It  is  much  more  frequent  in 
dark  races  and  in  some  tropical  climates  (West  Indies,  South  and 
Central  America). 


THE    ACQUIRED    NEUROSES.  515 

Symptoms. — The  disease  sets  in  from  five  to  fifteen  days  after 
infection.  It  begins  with  feelings  of  stiffness  in  the  neck  and  throat 
and  sometimes  with  chilly  feelings.  Gradually  tonic  spasms  develop 
which  involve  the  trunk  muscles,  causing  opisthotonos  and  other 
forms  of  rigid  spasm.  Trismus,  or  lockjaw,  also  occurs.  The  spasms 
are  attended  with  intense  pain.  Sometimes  there  is  a  rise  of  tem- 
perature and  this  may  be  very  high.  The  disease  lasts  from  two  to 
five  weeks.  There  is  evidence  of  irritation  and  congestion  of  the 
spinal  cord  and  injured  nerves,  but  no  special  anatomical  changes 
are  found.  A  specific  bacillus  producing  a  tetanizing  poison  has 
been  discovered. 

The  diagnosis  is  based  on  the  characteristic  history  and  the  pe- 
culiar spasms.  In  strychnine  posioning  there  is  no  initial  trismus 
or  epigastric  pain.  In  rabies  there  is  also  no  trismus  but  a  respira- 
tory spasm  on  attempts  to  swallow. 

The  prognosis  is  bad.  About  eighty  per  cent  of  traumatic  and 
sixty  per  cent  of  idiopathic  cases  die. 

The  treatment  consists  of  complete  rest  and  quiet  in  a  dark  room 
and  the  administration  of  chloral,  bromide,  morphine,  and  physo- 
stigma.  Successful  results  from  injection  of  blood  serum  of  an  animal 
which  has  had  the  disease  are  reported.  A  tetanus  antitoxin  has 
also  been  tried  with  some  success,  and  this  has  even  been  injected 
into  the  subdural  cavity  of  the  brain,  but  the  results  are  not  yet 
very  satisfactory. 


Tetaxy  (Tetanilla). 

Tetany  is  a  subacute  or  chronic  spasmodic  disorder  characterized 
by  intermittent  or  persistent  tonic  contractions  beginning  in  the 
extremities  and  associated  with  paraesthesise  and  hyperexcitability 
of  the  motor  and  sensory  nerves. 

Etiology. — The  disease  is  very  rare  in  this  country,  but  relatively 
common  in  Europe,  especially  in  Austria.  It  occurs  with  frequency 
during  the  second,  third,  and  fourth  years  of  life  and  again  at  the 
time  of  puberty.  Its  rate  of  frequency  then  slowly  declines  and  it 
is  very  rare  after  fifty.  It  affects  males  much  oftener  than  females 
up  to  the  age  of  twenty;  after  that  the  difference  disappears.  It 
occurs  mostly  in  the  working  classes.  In  infants  rickets  is  often 
noted.  The  exciting  causes  are  exhausting  influences  like  diarrhoea, 
lactation,  sepsis,  fatigue,  mental  shock,  and  fevers;  also  exposure 
to  cold  and  wet.  Alcoholism,  dilatation  of  the  stomach,  and  intes- 
tinal entozoa  are  also  causes.  It  may  be  produced  artificially  by 
extirpation  of  the  thyroid  gland.  The  disease  sometimes  appears 
as  an  epidemic. 

Symptoms. — Tetany  begins  sometimes  suddenly  with  symmetrical 


51  6  DISEASES    OF   THE    NERVOUS    SYSTEM. 

tonic  contractions  of  the  hands;  at  other  times  there  are  at  first  sen- 
sations of  numbness,  prickling  or  pain  in  the  extremities,  with  mal- 
aise and  perhaps  nausea;  then  spasms  begin.  The  attacks  affect 
first  and  most  the  upper  extremities.  The  flexors  of  the  forearm 
and  hand  are  usually  involved;  the  fingers  are  flexed  at  the  meta- 
carpo-phalangeal  joint  and  extended  at  the  other  joints,  and  the 
thumb  is  adducted,  producing  the  "accoucheur's  hand."  The  fore- 
arm may  be  flexed  and  the  upper  arm  adducted.  The  knees  and 
feet  are  extended,  the  toes  flexed,  and  the  foot  is  inverted.  In  severe 
cases  the  muscles  of  the  abdomen,  chest,  neck,  and  face  are  in- 
volved. Opisthotonos  and  dyspnoea  may  result.  The  muscles  of  the 
face  and  eyes  develop  contractions,  and  trismus  sometimes  occurs 
late  in  the  disease.  The  muscles  of  the  larynx,  oesophagus,  and 
bladder  may  be  affected.  Fibrillary  tremors  are  observed  in  the 
contracted  muscles.  The  attacks  aie  accompanied  by  pareesthesias 
and  cramp-like  pains.  There  may  be  some  abolition  of  sensation 
in  the  skin  of  the  parts  affected  during  attacks.  The  cramps  last 
from  a  few  minutes  to  hours  or  days.  They  occur  during  clay  and 
night  and  may  wake  the  patient  from  sleep.  Fever  is  sometimes 
present  in  epidemic  cases.  The  disease  has  a  tendency  to  recur- 
rence. 

While  it  lasts,  both  during  and  between  the  attacks  peculiar 
phenomena  are  observed  as  follows : 

1st.  Increased  Mechanical  Irritability  of  Motor  Nerves. — The 
motor  nerves  show  an  abnormal  irritability,  so  that  on  striking  the 
motor  point  a  sharp  muscular  contraction  is  brought  out.  When 
pressure  or  a  blow  is  made  on  the  face  over  or  near  the  exit  of  the 
facial  nerve  from  its  foramen,  contractions  of  the  facial  muscles 
occur,  especially  those  of  the  lips.  This  is  called  the  "  facial  phe- 
nomenon." By  pressing  on  the  artery  and  nerve  of  a  limb  a 
tetanic  attack  can  be  produced  in  the  muscles  supplied.  It  is  prob- 
able that  it  is  the  pressure  on  the  nerve  alone  which  causes  the 
phenomenon  which  is  called  "Trousseau's  symptom." 

2d.  The  electrical  irritability  of  the  muscles  and  nerves  is  in- 
creased, especially  to  the  galvanic  current.  Thus  a  negative-pole 
closure  contraction  (CaCC)  is  brought  out  by  a  very  weak  current; 
and  if  a  little  stronger  it  causes  a  tonic  contraction  or  cathode-closure 
tetanus  (CaCTe).  The  positive-pole  opening  contraction  (AnOC) 
may  be  tetanic,  i.e.,  AnOTe,  and  there  may  be  even  a  cathode- 
opening  tetanus  (CaOTe),  a  phenomenon  not  seen  in  any  other  dis- 
ease. According  to  Gowers  there  may  be  a  reversal  of  the  polar 
formula,  so  that  a  positive-pole  closure  contraction  occurs  earlier 
than  a  negative  (AnCC>CaCC).     This  is  certainly  rare. 

3d.  An  increase  of  irritability  of  the  sensory  nerves  is  shown  by 
pressing  upon  them,  when  sensations  of  prickling  and  formication 
appear  along  their  course.  There  is  an  increase  also  in  the  elec- 
trical sensibility,  shown  by  appreciation  of  very  weak  galvanic  cur- 
rents. The  auditory  nerve  reacts  to  the  galvanic  current  in  about 
fifteen  per  cent  of  normal  cases,  and  then  only  to  strong  currents 


THE    ACQUIEED    NEUROSES.  517 

and  to  only  a  partial  extent;  but  in  tetany  it  reacts  in  nearly  all 
cases,  and  with  comparatively  weak  currents  (2  to  5  or  6  ma.)  on 
anode  closure,  anode  fixed,  and  anode  opening  (AnC  Klang,  AnDKl, 
AnOKl)   (Chvostek). 

The  phenomena  of  hyperexcitability  above  described  vary  con- 
siderably and  rapidly  during  the  comse  of  the  disease,  and  are  not 
always  present. 

Types  of  the  Disease. — The  disease  varies  in  intensity  and  dura- 
tion. This  variation  depends  much  upon  the  cause,  and  there  have 
been  made  a  number  of  types  of  the  disease  based  on  the  etiology. 
Thus  we  have : 

1.  Epidemic  or  rheumatic  tetany. 

2.  Asthenic  tetany  due  to  lactation,  diarrhoea,  exhausting  dis- 
eases, etc. 

3.  Thyroid  tetany,  due  to  removal  of  the  thyroid  gland. 

4.  Reflex  tetany  from  gastric  dilatation  and  intestinal  worms. 

5.  Latent  forms  of  tetany  in  which  the  phenomena  of  hyper- 
excitability and  parsesthesia  occur  with  very  slight  if  any  contrac- 
tions, and  no  Trousseau  symptom. 

Infantile  tetany  should  perhaps  be  separated  from  other  forms. 

Symptomatic  tetany  from  brain  disease  is  also  spoken  of. 

When  the  spasms  are  continuous  the  disease  lasts  but  a  few 
weeks;  when  they  are  intermittent  it  may  continue  for  months. 
Epidemic  cases  last  but  a  few  weeks.  The  disease  may  be  said  in 
general  to  last  from  a  few  weeks  to  a  few  months.  Patients  are 
liable  to  a  recurrence  on  return  of  the  exciting  cause. 

Pathology. — 'The  phenomena  of  the  disease  indicate  a  congested 
and  irritative  condition  of  the  gray  matter  of  the  spinal  cord.  The 
cause  of  this  state  is  evidently  in  some  cases  (epidemic  tetany)  an 
infectious  poison  ;  in  other  cases  mucin  in  the  blood  (thyroid  tetany), 
and  in  other  cases  it  may  be  a  rheumatic  or  some  other  toxic  influ- 
ence.    Ergot  is  known  to  produce  symptoms  resembling  tetany. 

In  infantile  tetany  the  irritation  is  apparently  cortical  and  due 
to  meningitis  or  to  rickets  and  the  reflex  irritation  of  disordered 
bowels.  It  is  doubtful  if  any  reflex  influence  can  be  invoked  in 
adults.  Tetany  is  a  functional  disease  and  the  symptomatic  ex- 
pression of  a  central  irritation.  This  irritation  may  be  of  different 
kinds,  hence  tetany  has  a  claim  to  be  called  a  distinct  disease  sim- 
ply on  clinical  grounds.  It  has  no  such  definite  pathology  as 
chorea  or  epilepsy.  In  the  very  few  autopsies  which  have  been 
made  no  definite  organic  lesion  has  been  found. 

Diagnosis.  — The  disease  is  usually  easily  recognized  by  the  char- 
acter of  the  spasms,  their  symmetrical  nature,  their  course,  and  the 
phenomena  of  hyperexcitability  of  the  muscles  and  nerves.  Trous- 
seau's symptom  is  found  in  no  other  disease.  The  "facial  phe- 
nomenon," the  peculiar  electrical  and  mechanical  irritability  of  the 
muscles  and  nerves,  are  very  rare  in  other  conditions.  The  sensory 
irritability,  and  especially  that  of  the  acoustic  nerve,  is  also  charac- 
teristic.    From  tetanus  the  disease  is  distinguished  by  the  intermit- 


518  DISEASES    OF   THE    NERVOUS   STSTEM. 

tency  of  the  contractions,  their  feebler  character,  the  fact  that  they 
begin  in  the  extremities  and  extend  to  the  trunk,  and  by  the  absence 
of  trismus,  at  least  until  late  in  the  disease. 

Treatment. — The  cause  should  be  removed  if  possible,  lactation 
stopped,  diarrhoea  and  indigestion  corrected,  worms  expelled,  rickets 
if  present  attended  to.  Rest,  nourishing  food,  and  tonics  are  indi- 
cated. Symptomatically,  bromide  of  potassium  in  doses  of  3  iss.  to 
3  ij.  daily  with  chloral  furnishes  the  surest  relief.  Hyoscine  in 
doses  of  gr.  yi-^  may  be  tried.  Inhalation  of  chloroform  or  injec- 
tions of  morphine  are  needed  in  severe  cases.  In  nocturnal  tetany 
Gowers  advises  digitalis.  Lukewarm  baths  may  be  of  service ;  so 
also  may  ice  bags  to  the  spine.  If  electricity  is  used  only  the  weak 
galvanic  current  should  be  employed. 


CHAPTER   XXV. 

NEURASTHENIA     (NERVOUS     EXHAUSTION,     BEARD'S 

DISEASE). 

Neurasthenia  may  be  defined  as  a  chronic  functional  nervous 
disorder  which  is  characterized  by  an  excessive  nervous  weakness 
and  nervous  irritability,  so  that  the  patient  is  exhausted  by  slight 
causes  and  reacts  morbidly  to  slight  irritations. 

There  are  evidences  that  the  neuropathic  constitution  existed  in 
all  ages,  but  coherent  descriptions  of  clinical  types  like  the  neuras- 
thenia of  modern  days  are  not  found  in  literature  until  the  present 
century.  The  credit  of  calling  attention  to  this  condition  most  in- 
sistently, most  acutely,  and  most  successfully  is  due  to  Dr.  Geo.  M. 
Beard.  He  showed  that  a  large  class  of  symptoms  which  had  been 
previously  referred  to  hypochondriacal  fancy,  to  disease  of  the  stom- 
ach, disease  of  the  uterus,  perverted  conditions  of  the  liver  and 
urinary  excretions,  were  really  and  fundamentally  dependent  upon 
a  morbid  weakness  of  the  nerve  centres,  and  the  result  of  his  writ- 
ings and  the  propaganda  which  he  started  is  that  now  practically  all 
medical  men  of  experience  agree  that  there  is  a  morbid  condition  of 
which  the  underlying  cause  is  a  nervous  irritation  or  defect. 

Etiology. — Some  doubt  has  been  thrown  over  the  question  of  the 
excessive  nervousness  of  the  civilized  nations  of  the  present  time. 
It  is  not  a  matter  which  can  be  fairly  settled  by  statistics  or  the  pe- 
rusal of  historical  documents,  but,  on  the  whole,  the  evidence  is,  to 
my  mind,  conclusive  that  the  human  race  does  now  suffer  relatively 
more  from  nervous  irritability  and  exhaustion,  in  its  various  types, 
than  it  did  in  the  past.  This  I  infer  partly  from  the  fact  that  the 
predisposing  and  exciting  causes  of  neurasthenia  are  more  largely 
present  now  than  they  used  to  be.  The  tendency  of  people  to  city 
rather  than  rural  life  is  perhaps  one  of  the  strongest  points  in  favor 
of  this  view,  since  we  know  it  is  in  our  urban  population  that  neu- 
rasthenia breeds  best.  A  larger  proportion  of  persons  now  also  use 
their  brains  in  the  struggle  for  existence  and  live  upon  a  higher 
mental  plane,  with  all  the  danger  which  that  implies.  The  eigh- 
teenth-century writers  attributed  all  the  functional  disorders  then 
known,  under  the  terms  "vapors,"  "spleen,"  "  hypochondria, "' 
"hysteria,"  to  three  things — luxurious  living,  sedentary  life,  and 


520  DISEASES   OF    THE    NERVOUS    SYSTEM. 

the  unsanitary  conditions  of  great  and  populous  cities.  They  said 
nothing  about  the  effects  of  overwork,  continual  anxiety,  and  mental 
strain,  and  one  certainly  does  not  gain  from  reading  the  English 
medical  literature  of  this  period  that  there  was  any  such  excess  of 
work  and  worry  among  the  people. 

Without  going  into  any  further  argument  upon  this  point,  I  shall 
admit,  as  an  offset  to  this,  the  more  widespread  knowledge  of  how 
to  live  and  how  to  ward  off  disease,  so  that  it  is  at  least  probable 
that  even  if  neurasthenia  is  more  prevalent  now,  and  has  been 
steadily  increasing,  this  will  not  necessarily  always  continue  to  be 
the  case. 

At  the  present  time  we  know  that  neurasthenia  is  found  more 
frequently  among  the  highly  cultivated  races.  I  have  seen  it  in 
negroes,  but  it  is  extremely  rare,  while  hysteria  and  insanity  are 
fairly  common.  I  believe  that  Americans  deserve  to  an  extent  the 
reputation  which  they  have  of  suffering  greatly  from  neurasthenia. 
This  is  particularly  the  case  in  the  Northern  and  Central  States, 
on  the  Colorado  plateau,  in  parts  of  California,  and  in  the  great 
cities  of  the  East.  Neurasthenia  is  said  to  be  quite  prevalent  in 
Russia,  and  it  is  generally  observed  that  it  affects  particularly  often 
the  Hebrew  race.  In  this  country  we  see  it  quite  often  in  the  Irish, 
but  almost  as  often  in  the  English,  and  rather  less  frequently  in  my 
experience  in  the  Germans.  Neurasthenia  prevails  rather  more  in 
dry  temperate  climates,  but  it  is  by  no  means  infrequent  in  the 
tropical  regions,  and  is  to  be  found  in  the  West  Indies  and  in  the 
republics  of  South  and  Central  America  in  its  classical  forms. 
Neurasthenia  is  found  rather  more  often  in  men  than  in  women, 
but  the  difference  is  not  great.*  Among  828  neurasthenics  whose 
histories  were  analyzed  by  Hosslin,  there  were  604  men  and  224 
women,  but  this  does  not  give  the  proper  ratios  if  we  include  all 
grades  of  society. 

The  neurasthenic  age  ranges  from  eighteen  to  fifty -five,  but  the 
larger  proportion  of  cases  is  met  with  between  the  years  of  twenty 
and  fifty.  Occasionally  symptoms  resembling  neurasthenia  may  be 
seen  in  children  of  the  age  of  twelve  or  thirteen,  and  occasionally 
also  there  develops  a  kind  of  senile  neurasthenia,  which  is,  how- 
ever, often  associated  with  hypochondriasis,  and  some  definite 
degenerative  changes  in  the  nervous  or  vascular  system. 

*  Among  100  consecutive  personal  cases  there  were  53  women,  47  men. 
Ages  :  fifteen  to  twenty -five,  25  ;  twenty-six  to  thirty -five,  38  ;  thirty -six  to 
forty-five,  25 ;  forty-six  to  fifty-five,  20 ;  fifty -six  to  sixty -five,  2.  There 
are  relatively  more  cases  in  the  adolescence  of  man  and  in  the  later  period  of 
life  of  women.  Nativity:  United  States,  59 ;  Ireland,  29;  Germany,  12; 
others,  9. 


NEURASTHENIA.  521 

In  men  neurasthenia  occurs  more  often  in  the  single ;  in  women 
the  relation  is  somewhat  reversed,  so  that,  taking  both  classes,  the 
married  and  the  unmarried  are  about  equal. 

Neurasthenia  does  not  much  affect  the  people  of  the  country  and 
small  towns,  though  it  does  exist  there.  In  great  cities  the  number 
of  neurasthenic  women,  among  the  wives  of  laborers  and  artisans, 
is  rather  large,  and  this  is  the  natural  result  of  the  strain  of  living 
with  husbands  who  are  dissipated,  and  of  rearing  large  families  of 
children  in  the  close  quarters  of  a  tenement  house.  The  disease  is 
relatively  more  frequent  in  the  educated  classes. 

Hereditary  influence  plays  a  very  considerable  part  in  the  de- 
velopment of  neurasthenia.  We  can  usually  find  that  there  is  a  his- 
tory of  migraine  or  some  nervous  irritability  upon  one  side  or  the 
other.  A  distinct  history  of  the  major  neuroses  or  of  severe  mental 
diseases  is  rare,  but  there  is  no  doubt  that  a  very  large  proportion 
of  neurasthenics  come  into  the  world  with  an  oversensitive  and 
weakened  nervous  system.  They  may  be  strong  enough  to  undergo 
the  ordinary  strain  of  life,  but  break  down  under  some  specially 
exciting  cause. 

The  exciting  causes  of  neurasthenia  are  very  various,  but  they 
can  most  of  them  be  classed  under  the  head  of  excessive  mental 
strain  or  shock,  sexual  abuse,  and  the  influences  of  exhausting  fe- 
vers, of  chronic  infections  like  syphilis,  and  of  poisoning  with  al- 
cohol and  tobacco  or  tea  and  coffee.  In  the  larger  proportion  of 
cases  of  men,  the  trouble  if  it  develops  during  adolescence  is  brought 
on  by  overwork  at  school  and  in  college,  combined  with  neglect  of 
sleep  and  carelessness  in  diet.  Frequently  the  abuses  of  the  sexual 
function,  of  tobacco,  or  of  athletics  are  the  exciting  causes. 

The  practice  of  masturbation  is  one  of  the  things  for  which  neu- 
rasthenics very  often  keenly  reproach  themselves  and  over  which 
much  hypochondriacal  brooding  develops.  Excesses  of  this  kind, 
however,  are  usually  a  sign  of  a  degenerate  or  unbalanced  nervous 
system  rather  than  a  cause.  The  actual  harm  done  is  greatly  exag- 
gerated, however  strongly  this  practice  is  to  be  reprobated.  Exces- 
sive and  unnatural  indulgences,  such  as  sodomy,  etc.,  tend  to  weaken 
the  nervous  system  and  arc  causal  factors  of  neurasthenia.  Bad 
methods  of  education  and  in  particular  excessive  study  are  thought 
to  predispose  to  nervous  exhaustion.  This  is  usually  seen  in  ambi- 
tious college  students,  or  in  young  men  who  are  forcing  their  way 
under  great  disadvantages  through  professional  schools  and  into 
professional  practice.  Young  women,  who  are  excessively  devoted 
to  study  and  yet  cannot  refrain  from  social  indulgences,  sometimes 
break  down  with  nervous  exhaustion.     The  studies  and  training  of 


522  DISEASES   OF   THE    NERVOUS    SYSTEM. 

the  primary  and  secondary  schools  may  prepare  the  way  for  these 
catastrophes,  but  they  rarely  come  before  the  eighteenth  year. 

Typical  attacks  of  neurasthenia  are  undoubtedly  brought  on  by 
the  fright  and  shock  incident  to  severe  injuries  or  exposure  to  great 
danger,  as  in  railroad  collisions  and  other  frightful  forms  of  acci- 
dent. A  large  proportion  of  the  so-called  "  traumatic  neuroses  "  are 
simply  forms  of  neurasthenia.  Neurasthenia  can  be  brought  on  also 
by  excessive  child-bearing,  the  drain  of  lactation  and  domestic  trou- 
ble, great  excesses  in  eating  and  drinking,  and  the  strain  of  hard 
domestic  life  and  of  sickness  and  nursing.  Neurasthenia  sometimes 
follows  an  acute  infection  like  that  of  typhoid  fever  or  the  grippe. 
It  may  also  be  induced  by  the  infection  of  syphilis.  It  then  comes 
on  in  the  secondary  or  less  often  in  the  tertiary  stage  (Fournier). 
It  is  probable  that  in  many  of  these  cases  the  trouble  is  due  to  the 
excessive  use  of  mercury  and  saline  purges.  At  any  rate  antisyph- 
ilitic  treatment  can  certainly  bring  on  or  bring  out  a  neurasthenia. 
A  combination  of  secondary  syphilis  with  the  excessive  use  of  alco- 
hol leads  to  a  very  obstinate  type  of  neurasthenia.  Malarial  poi- 
soning seems  also  to  have  some  influence  as  an  exciting  cause. 
Much  weight  has  been  laid  upon  the  importance  of  eye  strain  in 
producing  neurasthenia,  and,  given  a  neuropathic  constitution,  there 
is  no  doubt  that  the  defect  in  the  refraction  of  the  eye  or  in  mus- 
cular equilibrium  may  cause,  or  at  least  keep  up,  a  neurasthenic 
state.  The  same  is  probably  true  of  severe  forms  of  gastric  dis- 
turbance, and  of  disease  of  the  pelvic  organs,  such  as  subinvolution, 
decided  displacements,  and  chronic  ovaritis  or  salpingitis.  In  men 
the  existence  of  prostatic  irritation,  of  irritable  strictures,  and  hem- 
orrhoids and  fissures,  may  start  up  neurasthenic  symptoms.  Chronic 
middle-ear  disease  and  nasal  stenosis  are  also  put  down  as  occasional 
exciting  causes.  The  existence  in  neurasthenics  of  a  tendency  to 
constipation,  or  what  is  popularly  known  as  "biliousness,"  accom- 
panied by  a  gouty  or  lithsemic  diathesis,  has  been  much  dwelt 
upon,  and  at  one  time  neurasthenia  was  thought  to  be  largely  the 
expression  of  a  disturbed  state  of  the  metabolism — a  phase  only  of 
gout  or  lithsemia.  This  tendency,  however,  is  rather  the  result  of 
the  weak  nerve  centres  than  the  cause,  though  the  two  often  act  in 
a  vicious  circle.  Prolonged  and  severe  dyspeptic  disturbances,  es- 
pecially when  associated  with  atony  of  the  stomach  and  bowels  and 
the  condition  known  as  enteroptosis,  are  exciting  or  maintaining 
causes. 

I  would  sum  up  the  leading  causes  of  neurasthenia  thus : 

1.  Hereditary  nerve  sensitiveness. 

2.  Overwork  and  worry. 


NEURASTHENIA.  523 

3.  Severe  shocks,  with  or  "without  injury. 

4.  Infections. 

5.  Abuse  of  stimulants  and  narcotics. 

6.  Abuse  of  sexual  functions. 

7.  Disorder  of  digestive  functions  and  auto-toxaemia. 

This  means  that  the  causes  are  most  often  a  bad  heredity  and 
foolish  living. 

A  great  deal  of  stress  has  been  laid  upon  autotoxeemia  as  a  cause 
of  neurasthenia.  There  is  no  doubt  that  a  great  many  symptoms 
and  crises  are  brought  about  through  this  agency,  but  the  attempts 
to  prevent  autotoxaemia  by  perpetually  stimulating  the  liver  and 
giving  intestinal  antiseptics,  of  using  a  large  amount  of  water  and 
the  simplest  kind  of  diet,  do  not  of  themselves  cure  the  disease, 
unless  measures  are  taken  to  strengthen  the  impaired  tone  of  the 
general  system. 

Symptoms. — The  symptoms  of  neurasthenia,  while  manifold, 
have  yet  a  pretty  distinct  general  resemblance  to  each  other,  and 
the  clinical  picture  of  typical  forms  of  neurasthenia  is  quite  as  pro- 
nounced as  that  of  other  nervous  maladies.  The  patient's  symptoms 
are  to  be  sure  nearly  always  of  the  subjective  character,  but  they 
are  reiterated  with  so  much  force  and  feeling,  and  the  independent 
descriptions  tally  so  closely,  that  one  can  hardly  fail  to  be  con- 
vinced by  the  story  itself  that  they  are  expressions  of  the  same 
morbid  condition. 

The  patient  complains  of  a  general  feeling  of  mental  depression 
— life  is  not  the  interesting  spectacle  to  him  that  it  formerly  was. 
The  man  who  once  delighted  in  work  can  hardly  force  himself  now 
to  go  to  it.  He  tires  very  quickly  over  tasks  which  were  formerly 
easily  performed.  He  loses  his  power  of  originating  plans  and  of 
mapping  out  work.  He  absolutely  cannot  pursue  a  train  of  thought 
or  a  single  line  of  work  for  a  long  time,  but  sits  idly  at  his  desk  or  goes 
back  to  his  home  in  depression  and  despair.  He  is  very  easily  irri- 
tated at  things  which  before  caused  him  no  annoyance,  and  becomes 
a  source  of  domestic  unrest  and  unhappiness.  He  is  oppressed  with 
the  fear  that  he  will  never  get  well,  or  is  going  to  become  insane  or 
paralyzed,  or  that  some  dreadful  termination  of  his  present  malady 
is  bound  to  occur.  He  sleeps  badly,  waking  up  perhaps  alter  a 
short  rest  in  the  early  part  of  the  night,  or,  if  he  sleeps  until  morn- 
ing, he  has  disquieting  dreams,  and  wakes  up  unrefreshed.  He 
suffers  from  a  number  of  peculiar  sensations  which  are  called 
"cephalic  paraesthesiae."  These  are  sensations  of  pressure  on  the 
top  of  the  head,  or  a  feeling  of  constriction  around  the  temples,  or 
a  burning  spot  on  the  vertex,  or  tenderness  of  the  scalp.     Sometimes 


524  DISEASES    OF   THE   NERVOUS   SYSTEM. 

he  has  a  sense  of  weakness  or  even  pain  in  the  back  of  the  neck. 
He  has  also  peculiar  paraesthesiae  of  the  hands  and  limbs;  they  feel 
numb  or  asleep  at  times.  Peculiar  chilly  sensations  creep  up  the 
back  or  legs.  He  less  often  has  attacks  of  dizziness ;  spots  come 
before  the  eyes  and  buzzing  sounds  are  heard  in  the  ears  and  head. 
Headache  occurs  in  perhaps  one-half  of  the  cases,  the  headache 
being  usually  either  frontal  or  occipital.  It  is  often  very  persistent, 
and  in  fact  a  chronic  headache,  not  due  to  tumor  or  meningitis  or 
syphilis,  is  almost  invariably  of  neurasthenic  origin.  This  neuras- 
thenic headache  is  usually  diurnal  ouly,  coming  on  in  the  morning 
when  the  patient  wakes  up,  and  lasting  a  good  part  of  the  day.  It 
does  not  often  keep  him  awake  at  night.  In  this  point  it  is  distin- 
guished from  the  headaches  of  syphilis  and  of  meningitis  or  of  tu- 
mors. Women  suffer  from  these  headaches,  and  from  pains  in  gen- 
eral, more  often  than  men.  They  in  particular  have  much  pain  in 
the  back  of  the  neck  and  along  the  spine.  This  keeps  them  from 
walking  or  being  upon  their  feet,  and  it  may  develop  into  a  form  of 
neurasthenia  known  as  "  spinal  irritation." 

The  special  senses  are  not  very  seriously  affected.  The  patients 
can  often  see  quite  well,  but  their  eyes  soon  tire ;  the  effect  of  watch- 
ing a  play  fatigues  them.  They  cannot  read  a  book  long  because  it 
makes  the  eyes  smart  or  produces  some  headache.  Examination  of 
the  neurasthenic's  eye  frequently  shows  the  existence  of  some  re- 
fractive error,  most  frequently  astigmatism  and  hy permetropia ;  de- 
fects in  the  ocular  muscles,  and  especially  weakness  of  the  internal 
recti,  often  occur.  Patients  have  frequently  complained  to  me  of 
a  defect  in  visual  memory.  They  see  a  thing  or  face  but  do  not 
remember  it  again  as  readily  as  they  used  to.  There  is  no  limita- 
tion of  the  visual  field  in  true  neurasthenia  uncomplicated  by  or- 
ganic disease,  but  there  is  a  morbid  susceptibility  to  fatigue,  par- 
ticularly of  the  periphery  of  the  vision,  so  that,  after  long  testing, 
objects  in  the  periphery  become  less  distinct,  and  a  sort  of  artificial 
limitation  of  the  field  may  be  produced.  In  some  cases  an  object 
which  is  brought  from  without  into  and  across  the  visual  field  is 
seen  in  wider  range  than  an  object  which  is  placed  in  the  centre  of 
vision  and  carried  gradually  out  toward  the  periphery.  This  is  the 
reverse  of  the  normal  condition,  and  is  known  as  "Foerster's  shift- 
ing type."  Peculiarities  of  accommodation,  a  slight  drooping  of  the 
lids,  inequality  of  the  pupils,  and  excessive  mobility  of  the  iris  have 
been  noted  in  neurasthenia. 

As  I  have  alreadly  stated,  neurasthenics  sometimes  suffer  from 
tinnitus,  which  is  very  distressing  and  aggravates  every  other  ner- 
vous symptom,  but  this  usually  occurs  only  in  connection  with  ac- 


NEUEASTHEN"IA.  525 

trial  disease  of  the  middle  ear,  or  in  old  people  with  degenerative 
changes  in  the  cerebral  blood-vessels.  An  excessive  sensibility  to 
noises,  and  even  the  pleasant  sounds,  like  those  of  music,  may  be 
present.  Neurasthenics  sometimes  cannot  bear  even  the  most  en- 
chanting melodies.  A  similar  morbid  sensibility  to  taste  and  smell 
may  be  present.  But  these  are  matters  of  minor  moment,  and  are 
much  more  often  seen  in  hysteria  or  in  a  hystero-neurasthenia. 

There  is  no  doubt  in  my  mind  that  in  neurasthenics  the  general 
muscular  and  nervous  strength  is  lessened,  and  although  the  patient 
may  not  have  lost  flesh,  and  may  not  appear  particularly  weak,  he 
tires  quickly  on  ordinary  exertion,  and  the  tests  of  the  dynamometer 
show  a  lessened  response.  A  fine  tremor  of  the  hands  is  often 
present,  and  when  the  eyes  are  tightly  closed  there  will  be  a  quiv- 
ering of  the  lids,  and  in  very  acute  and  exaggerated  cases  twitch- 
ings  of  the  muscles  of  the  face  and  tongue,  almost  like  those  in  gen- 
eral paresis.  This  rarely  occurs,  however,  unless  the  patient  has,  in 
addition  to  the  neurasthenia,  a  considerable  amount  of  toxaemia  from 
alcohol,  tobacco,  or  tea. 

The  reflexes  are  exaggerated  very  greatly.  In  many  cases  a 
blow  upon  the  leg,  anywhere  from  the  patella  to  the  middle  of  the 
shinbone,  will  bring  out  a  prompt  reaction,  and  similarly  a  blow 
struck  on  the  thigh  anywhere  from  the  patella  up  half-way  along 
the  thigh,  will  produce  a  knee  jerk.  And  blows  upon  the  motor 
points  promptly  bring  out  responsive  contractions.  The  cutaneous 
reflexes  are  also  exaggerated.  These  things  vary  considerably,  how- 
ever, in  different  cases,  and  are  more  marked  in  the  younger  patients 
and  those  of  a  neuropathic  constitution. 

The  sexual  function  is  irritable  and  weak. 

There  is  a  considerable  disturbance  of  the  heart  function  in 
neurasthenia.  The  most  frequent  condition  is  an  acceleration  of  the 
pulse  beat  from  very  slight  cause,  due  to  a  weakening  of  the  inhibi- 
tion of  the  heart.  A  pressure  over  some  painful  point  in  the  body 
will  sometimes  bring  Tip  the  pulse  from  80  or  90  to  over  100,  and 
it  will  remain  there  for  one  or  two  minutes.  This  is  called 
"  Rumpf's  symptom."  Arrhythmia  and  palpitation  of  the  heart 
are  less  frequently  observed.  It  is  my  belief  that  cardiac  weakness 
is  an  important  condition  in  many  forms  of  neurasthenia  and  under- 
lies sometimes  a  good  many  of  the  other  symptoms.  This  is  partic- 
ularly true  of  the  neurasthenias  of  more  advanced  life.  The  cardiac 
disturbances  are  more  frequent  in  women,  in  young  people,  and  in 
neurasthenia  associated  with  the  use  of  tobacco  and  tea. 

A  great  deal  of  emphasis  has  been  laid  upon  the  vasomotor  dis- 
turbances of  neurasthenia,  and  a  large  number  of  neurasthenic  symp- 


526  DISEASES   OF   THE    NERVOUS    SYSTEM. 

toms  have  been  ascribed  to  a  weakening  of  the  vasomotor  centre. 
As  a  result  of  this  the  patient  suffers  from  cold  hands  and  feet,  from 
flushing  of  the  face  alternating  with  pallor,  from  dermographic 
skin,  and  from  those  symptoms  which  we  usually  attribute  to  cere- 
bral congestion,  such  as  a  sense  of  fulness  in  the  head,  headache, 
spots  before  the  eye,  dizziness,  and  noises  in  the  head.  Sphygmo- 
grams  of  the  pulse  show  a  lowering  of  arterial  tension,  and  perhaps 
still  more  a  great  variability  in  the  tension  of  arteries.. 

The  condition  of  the  urine  has  been  studied  ver}T  closely  in  con- 
nection with  this  subject.  In  fact  many  of  the  symptoms  which  we 
now  call  "  neurasthenic"  were  described  by  Dr.  Prout  and  Dr.  Gold- 
ing  Bird  early  in  the  century  and  were  held  by  these  gentlemen  to 
be  due  to  oxaluria.  This  was  a  condition  characterized  by  flatulent 
dyspepsia,  melancholia,  and  nervous  irritability,  and  was  thought 
to  be  due  to  defective  metabolism,  resulting  in  the  production  of  an 
excess  of  oxalic  acid.  More  recent  studies  have  shown  that  oxaluria 
is  only  one  of  the  manifestations  of  lithsemia,  and  that  while  it  is 
significant,  as  was  then  supposed,  of  defective  nutritive  changes, 
these  are  more  dependent  on  a  neurasthenic  state  than  primarily 
upon  dyspepsia  and  metabolic  disorder.  There  are,  according  to 
Herter,  few  cases  of  neurasthenia  which  do  not  show  in  the  urine 
or  faeces  some  indication  of  defective  metabolism.  "  The  faeces  often 
contain  excessive  amounts  of  urobilin  or  some  related  substance. 
The  urine  is  usually  concentrated  and  of  small  volume  (600  to  1000 
c.c.  in  twenty-four  hours).  Frequently  there  is  an  excessive  excre- 
tion of  phosphoric  acid  (P206)  and  an  alteration  in  the  quantitative 
relation  of  urea  and  uric  acid.  In  health  the  relation  of  the  uric 
acid  to  the  urea  excreted  varies  between  1  to  45  and  1  to  60  in 
adults.  In  neurasthenia  (as  well  as  some  other  conditions)  the  re- 
lation is  often  1  to  40,  1  to  35,  or  1  to  30.  Indican  is  often  present 
in  pathological  quantities,  especially  in  cases  of  sexual  neurasthenia. 
Oxalate  of  lime  is  often  present  in  excess  in  the  urine"  ("  Diag- 
nosis of  Nervous  Diseases,"  p.  547). 

In  rare  cases  one  finds  in  neurasthenics  a  temporary  albuminuria; 
I  have  observed  it  only  once  in  one  hundred  cases,  which  is  about 
the  average.  This  albuminuria  is  not  associated  with  the  presence 
of  casts  or  other  evidence  of  kidney  disease,  and  it  is  apparently  due 
to  a  paresis  of  the  vasomotor  nerves  of  the  kidneys.  Transitory 
glycosuria  is  more  often  found.  This  glycosuria  is  usually  associ- 
ated with  a  heavy  urine  and  evidences  of  lithgemia.  Some  authors 
(Hosslin,  Dercum)  state  that  there  is  an  excess  of  uric  acid  very 
uniformly  in  neurasthenia,  and  that  this  uric  acid  results  from  a 
breaking-up  of  the  nuclein  of  the  cells.     It  has  been  ingeniously 


NEUKASTHENIA.  527 

suggested,  therefore,  that  since  the  nuclei  of  nerve  cells  become 
smaller  and  irregular  in  shape  when  the  cell  is  exhausted,  it  is  from 
this  source  that  the  uric-acid  excess  comes.  All  observation,  how- 
ever, shows  that  excessive  use  of  nervous  tissue  leads  to  an  exces- 
sive excretion  of  phosphoric  acid  rather  than  of  the  urates.  My 
experience  in  studying  the  urine  of  neurasthenia  is  that  in  the 
younger  cases,  with  a  strong  neuropathic  taint,  it  is  variable  in 
specific  gravity,  but,  on  the  whole,  rather  low ;  and  that  the  daily 
amount,  as  Dr.  Herter  states,  is  below  the  average.  It  is  of  a  low 
specific  gravity  also  in  neurasthenia  occurring  after  middle  life, 
when  the  arterial  changes  of  that  period  begin  to  set  in.  In  early 
adult  life  the  urine  is  more  often  found  to  be  condensed,  as  others 
have  observed,  and  to  contain  the  products  of  defective  metabolism. 
The  urine  thus  shows  either  a  weakened  and  slowed- up  nitrogenous 
metabolism  or  a  perverted  metabolism.  The  important  things  to 
determine,  then,  in  examining  the  urine,  after  excluding  such  evi- 
dences of  serious  change  as  albumin  and  sugar,  are:  the  specific 
gravity  and  the  daily  amount,  the  amount  of  phosphates,  the  amount 
of  urates  and  uric  acid  and  their  relation  to  each  other,  and  finally, 
the  presence  of  indican  or  other  products  of  perverted  nutrition  and 
digestion.  I  do  not  find  indican  very  often,  and  practically  never 
in  the  light  urines. 

The  digestion  of  neurasthenics  is  often  more  or  less  affected,  and 
a  large  proportion  of  them  are  probably  treated  mainly  for  their 
stomach  conditions.  I  do  not,  however,  usually  find  cases  of  seri- 
ous and  genuine  gastric  disturbance.  In  the  majority,  under  proper 
treatment  and  proper  diet,  the  tongue  soon  cleans  off,  and  the  pa- 
tient complains  relatively  little  of  the  stomach,  though  his  nervous 
symptoms  continue.  The  neurasthenic,  it  is  true,  has  always  a 
feeble  digestion,  and  has  to  take  great  care  of  what  he  eats  and 
drinks,  but  when  he  is  put  upon  the  kind  of  diet  that  he  should  take 
the  stomach  gives  relatively  little  trouble.  This  is  especially  true  of 
the  younger  cases.  The  common  form  of  dyspepsia  is  one  which  is 
associated  with  acidity,  flatulence,  some  epigastric  uneasiness,  and 
constipation.  The  tongue  is  often  furred,  there  is  a  disagreeable 
taste  in  the  mouth,  and  frequently  anorexia.  It  is  only  in  patients 
who  have  abused  themselves  with  alcohol  or  tobacco  or  excessive  in- 
dulgence in  sweets,  or  with  ravenous  feeding,  that  worse  conditions 
are  found.  In  people  of  more  advanced  age,  however,  feebleness  of 
digestion  is  often  associated  with  a  relaxation  of  the  stomach  and 
intestinal  walls,  and  a  great  deal  of  atony  of  the  whole  intestinal 
tract.  In  these  cases,  which  we  find  particularly  often  in  women, 
there  may  be  a  weakness  of  the  abdominal  walls,  and  with  it  a  cer- 


528  DISEASES   OF   THE  JSTEKVOUS   SYSTEM. 

tain  amount  of  prolapse  of  the  large  bowel  and  stomach,  with  a  great 
many  distressing  symptoms  resulting  therefrom.  This  condition 
has  been  described  by  Glenard  under  the  name  of  "  enteroptosis, " 
and  it  undoubtedly  is  an  important  factor  in  keeping  up  the  neuras- 
thenia of  some  women  in  adult  and  middle  life. 

Among  the  most  serious,  though  fortunately  rare,  symptoms  of 
neurasthenia  involving  the  digestive  tract  is  the  condition  known 
as  "  mucous  euteritis."  This  trouble  generally  attacks  women  rather 
than  men,  and  usually  women  between  the  ages  of  twenty- five  and 
fort}-.  It  comes  on  after  the  patient  has  become  exhausted  by  pro- 
longed domestic  cares  and  fashionable  dissipation,  or  some  shock. 
It  is  one  of  the  earlier  symptoms  of  the  nervous  weakness,  and  be- 
gins with  abdominal  pain,  followed  by  attacks  of  diarrhoea,  in  which 
tubular  casts  are  passed,  or  portions  of  such.  This  diarrhoea  is 
painful,  colicky,  and  alternates  with  periods  of  constipation.  There 
is,  in  my  experience  and  in  that  of  others,  a  somewhat  spastic  con- 
dition of  the  bowel,  as  though  it  were  irritated  and  closed  down 
upon  the  contents  of  the  intestine.  The  term  mticous  enteritis  is 
not  strictly  a  proper  one,  since  microscopical  examinations  and  au- 
topsical  reports  show  that  the  substances  thrown  off  are  not  mucous 
mainly  and  that  there  is  no  actual  inflammation.  The  casts  that 
are  found  in  the  stools  are  composed  principally  of  albuminous  sub- 
stances, the  product  apparently  of  the  decomposition  or  disintegra- 
tion of  the  epithelial  cells  of  the  intestinal  walls.  While  mucous 
enteritis  sometimes  occurs  in  persons  who  are  profoundly  asthenic 
without  any  decided  neurasthenia,  yet,  in  the  great  majority  of  cases, 
it  is  a  symptom  of  neurasthenia,  and  can  be  successfully  treated  only 
on  such  a  basis. 

The  respirations  in  neurasthenia  are  generally  normal,  but 
shallow  and  deficient  respiratory  expansion  sometimes  exists.  In 
women  particularly  I  have  often  found  that  there  was  an  actual 
inability  properly  to  expand  the  chest  and  inflate  the  lungs. 

The  temperature  is  normal,  and  a  very  variable  temperature  of 
the  skin  is  simply  dependent  upon  vasomotor  instability. 

The  composition  of  the  blood  is  often  quite  normal.  Hcsslin 
finds  that  even  in  those  patients  who  appear  to  be  anaemic  there  is 
a  normal  amount  of  haemoglobin ;  however,  anaemia  certainly  exists 
in  many  cases,  and  there  is  no  question  that  the  use  of  iron  is  often 
of  great  benefit. 

Variations  in  the  weight  of  the  neurotic  often  occur.  Neurotic 
patients  may  gain  or  lose  ten  or  twenty  pounds  within  a  year  or 
two.  The  secretions  of  the  skin  are  usually  increased,  and  the  pa- 
tient sweats  easily  and  profusely.     In  other  cases  of  a  less  irritative 


XEUKASTHEXIA.  529 

type  the  skin  is  inclined  to  be  dry.  Its  nutritional  condition  is 
poor,  the  hair  falls ;  and  according  to  Beard  there  is  a  tendency  to 
early  decay  of  the  teeth. 

The  foregoing  description  of  the  general  symptomatology  of  neu- 
rasthenia is  likely  to  confuse  the  reader  on  account  of  the  multiplicity 
and  wide  extent  of  the  symptoms.  It  is  quite  true  that  few  neuras- 
thenics have  all  of  the  symptoms  just  described,  and  it  is  still  more 
true  that  in  most  of  them  the  patients  have  certain  leading  and 
dominant  symptoms  which  annoy  and  depress  them,  and  that  the 
larger  proportion  of  the  manifestations  of  the  disorder  are  trivial  to 
them,  as  they  are  to  the  physician. 

The  Different  Forms  of  Neurasthenia. — The  peculiar  type 
of  neurasthenia  depends  mainly  upon  the  age,  the  sex,  and  the 
hereditary  endowments  of  the  individual. 

Primary  Neurasthenia. — Neurasthenia  appearing  at  the  time  of 
adolescence  is  much  more  apt  to  be  associated  with  a  primarily  weak 
nervous  constitution.  The  mental  symptoms  are  mainly  dominant, 
and  the  malady  takes  more  often  the  character  of  a  hypochondriasis, 
with  some  fixed  ideas,  or  morbid  fear,  such  as  suggest  an  incom- 
pletely developed  paranoia.  Naturally,  also,  at  this  time,  sexual 
ideas  and  sexual  symptoms  very  largely  predominate. 

Hystero-Neurasthenia, — In  women  neurasthenia  at  this  period  is 
often  associated  with  hysteria,  and  the  French  term  hystero-neuras- 
1 7/ <</>!</  is  frequently  a  very  apt  one  for  the  condition.  Nervous  and 
irritable  women  are  usually  %stero-neurasthenic.  In  other  cases, 
women  suffer  from  a  great  deal  of  pain  along  the  back,  and  that 
particular  condition,  known  as  "spinal  irritation,"  complicates  the 
neurasthenic  state. 

Acquired  Neurasthenia  and  Ltthayrma. — It  is  during  the  mature, 
active  life  of  men  and  women  that  the  more  typical  forms  of  neuras- 
thenia occur.  In  these  patients  the  element  of  heredity  is  less 
marked,  while  the  extrinsic  causes  of  neurasthenia,  such  as  excesses 
in  eating  and  drinking,  shocks,  injuries,  poisons,  syphilis,  and  gouty 
tendencies,  all  come  much  more  into  play. 

Climacteric. — In  neurasthenia  developing  in  middle  life  and  at 
the  period  of  the  climacteric,  the  disease  is  associated  with  the  nat- 
ural symptoms  that  come  from  beginning  degeneration  of  the  arte- 
ries and  a  diminished  resistance  of  the  body  generally.  There  is  a 
greater  physical  weakness,  and  we  often  see  at  this  time,  also,  neu- 
rasthenia associated  with  much  vasomotor  disturbance,  or  with  the 
psychoses,  such  in  particular  as  melancholia. 

Traumatic  Neurasthenia  and  Hystero-Neur asthenia.  —  After  re- 
ceiving an  injury  which  is  often  but  slight,  but  which  is  usually 
34 


530  DISEASES    OF   THE    NERVOUS   SYSTEM. 

accompanied  by  a  great  deal  of  fright  and  emotional  disturbance, 
the  patient  goes  to  his  home  feeling  perhaps  a  little  nervous  and 
shaken,  but  not  suffering  to  any  great  extent.  He  goes  to  bed  and 
sleeps;  he  wakes  up  the  next  morning  feeling  not  quite  so  well  as 
usual,  but  congratulating  himself,  perhaps,  on  having  gotten  off  so 
easily.  He  resumes  his  work  and  finds  that  he  can  do  it,  though 
with  not  quite  so  much  ease  as  usual  and  he  very  likely  suffers  from 
some  pain  due  to  a  strain  or  bruise  that  he  has  received.  In  a  few 
days — almost  always  within  a  week — he  begins  to  notice  that  he  is 
more  nervous  than  usual,  that  little  things  irritate  him  which  did 
not  do  so  before,  that  his  head  seems  somewhat  confused,  and  that 
the  effort  to  work  is  wearying.  His  sleep  is  disturbed,  and  he 
wakes  up  in  the  morning  unrefreshed  by  his  night's  repose.  He 
becomes  somewhat  despondent  over  his  condition,  and  thoughts  of 
paralysis  or  some  other  serious  ailment  annoy  him.  His  head 
aches,  the  pain  being  more  or  less  constant  and  diffused,  and  lo- 
cated usually  over  the  forehead  or  at  the  back  of  the  neck.  He 
has  unpleasant  sensations  in  the  head,  such  as  that  of  constriction 
or  pressure  or  scalding  feelings.  His  back  also  is  continually  pain- 
ful, and  walking  increases  it.  His  nervousness  becomes  mure 
marked,  and  close  examination  shows  a  little,  fine  tremor  in  the 
hands.  He  has  also  sometimes  creeping  sensations  over  the  body 
or  numb  feelings  in  the  extremities.  He  tires  very  easily.  He  is 
emotional,  and  becomes  more  despondent  as  the  days  go  on.  Some- 
times he  has  spots  before  his  eyes,  noises  in  his  head,  or  ringing  in 
the  ears.  Reading  is  laborious  and  increases  his  headache;  so  also 
does  attention  to  work.  His  appetite  becomes  capricious  and  his 
bowels  are  constipated.  He  suffers  somewhat  from  flatulency  and 
dyspepsia.  His  heart  palpitates  easily,  and  the  pulse  is  a  little  ac- 
celerated. Sometimes  for  a  few  days  there  is  a  little  weakness  about 
the  bladder  or  irritability  of  that  viscus.  His  sexual  power  is  di- 
minished; his  circulation  seems  rather  poorer  than  usual.  Very 
•slight  excitement  produces  sweating  of  the  hands  or  coldness  of  the 
•extremities.      He  loses  a  little  flesh. 

These  symptoms  may  be  several  weeks  in  developing,  and  dur- 
ing this  time  he  may  perhaps  consult  a  lawyer  about  his  case.  If 
so,  the  anxieties  of  litigation  begin  to  add  to  and  intensify  his 
troubles.  He  consults  a  physician,  and  the  physician  finds  the 
subjective  symptoms  that  I  have  mentioned.  Objectively,  when 
examined,  the  physician  will  discover  that  the  muscular  power  is 
somewhat  weakened,  that  there  is  a  certain  amount  of  the  fine 
tremor  perhaps  in  his  hands.  The  knee  jerks  and  elbow  jerks  are 
exaggerated ;  there  are  tender  points  along  the  spine  and  upon  the 


NEURASTHENIA.  531 

head.  In  making  him  stand  with  his  eyes  closed  there  is  a  certain 
amount  of  static  ataxia  discovered.  The  pupils  are  often  dilated 
and  mobile,  and  examination  of  the  visual  field  shows  sometimes  a 
slight  contraction,  at  other  times  the  "  shifting  type"  already  de- 
scribed. In  many  cases  a  degree  of  peripheral  retinal  anaesthesia 
will  be  discovered.  The  pulse  will  be  found  accelerated,  and  pres- 
sure on  a  tender  point  may  send  it  up  very  rapidly ;  a  slight  exer- 
tion will  also  accelerate  it.  There  will  be  something  apparent  in 
the  ph3rsiognomy  of  the  case  which  shows  the  man  to  be  in  a  ner- 
vous and  asthenic  condition.  Sometimes  the  pains  from  which  the 
patient  suffers  in  the  back  and  the  weariness  in  the  limbs  are  so 
great  that  he  remains  a  good  deal  of  the  time  in  bed.  In  all  cases 
he  will  assert  most  positively  that  he  is  unable  to  work  or  to  take 
that  interest  in  his  affairs  that  he  has  previously  done.  In  a  good 
many  cases  there  will  be  added  to  the  foregoing  picture  a  number  of 
symptoms  due  to  some  local  injury:  for  example,  the  arm  may  have 
been  wrenched  or  bruised,  and  the  result  may  be  a  certain  amount 
of  neuritis  and  weakness  or  pain  in  that  member;  in  other  cases  the 
back  may  have  been  so  severely  sprained  that  the  typical  symptoms 
of  spinal  irritation  ensue,  and  this  is  particularly  apt  to  be  the  case 
when  women  are  injured ;  in  other  cases,  again,  the  legs  may  have 
been  hurt  to  such  an  extent  that  a  sciatica  or  some  other  form  of 
neuralgia  develops. 

The  foregoing  symptoms,  varying  in  amount  and  degree,  will 
last,  with  little  change,  for  a  very  long  period  of  time.  If  the  case 
goes  into  litigation,  there  is  added  the  worriment  occasioned  by  hav- 
ing to  go  through  the  disturbing  experiences  of  trial  by  jury.  In 
many  cases,  after  the  trial  has  been  settled  and  damages  awarded 
or  otherwise,  the  patient  begins  to  mend,  and  in  a  certain  proportion 
of  cases  he  gets  completely  well.     This  is  not  invariably  the  rule. 

Spinal  Irritation  (Cerebro- Spinal  Irritation) .Spinal  irritation 
is  a  form  of  neurasthenia  in  which,  associated  with  the  general  neu- 
rasthenic symptoms,  are  certain  special,  painful  symptoms,  related 
chiefly  to  the  sensory  nerves  of  the  spine.  These  cases  have  in  the 
past  been  described  under  the  head  of  "  spinal  anaemia"  and  "  hy- 
peremia." They  may  develop  in  traumatic  neurasthenia.  The  pa- 
tients are  usually  young  women,  between  the  ages  of  sixteen  and 
twenty-five.  The  trouble  is  sometimes  brought  on  by  injuries  or 
by  a  physical  overstrain.  Sometimes  it  seems  to  be  associated  with 
a  natural  weakness  of  the  spinal  muscles  and  a  consequent  curva- 
ture. Sometimes  it  follows  acute  infectious  diseases.  The  patient 
begins  by  complaining  of  pain  in  the  back  usually  in  the  lower 
part — and   also  in  the  back  of  the  neck.     These   pains  occur  on 


532  DISEASES   OF   THE   NERVOUS   SYSTEM. 

standing  or  walking,  or  any  exertion,  and  are  so  severe  that  the  pa- 
tients in  the  course  of  a  few  weeks  or  months  give  up  attempting 
to  walk  about.  They  get  relief  and  comfort  in  bed,  and  so  they  go 
there  and  remain.  The  pains  are  of  a  heavy,  aching  character, 
increased  until  they  become  very  sharp  -when  attempts  at  movement 
of  the  trunk  are. made.  There  is  a  great,  deal  of  tenderness  to  pres- 
sure along  the  spinal  processes,  some  of  these  processes  being  much 
more  sensitive  than  others.  The  most  sensitive  points  are  usually 
in  the  back  of  the  neck  and  the  upper  dorsal  vertebras,  and  down  in 
the  lumbar  region.  There  is  some  pain  also  upon  pressure  alongside 
of  the  spinal  processes.  Painful  points  often  vary,  and  even1  in  a 
single  examination  the  patient  may  complain,  and  complain  honestly, 
of  different  sensitive  vertebrae.  Pressure  on  these  points  does  not 
often  bring  out  visceral  symptoms,  as  the  brothers  Griffin  taught. 
The  patients  suffer  much  from  headaches.  The  arms  are  often 
weak,  so  that  attempting  to  sew  or  write  or  hold  a  book  causes  pain 
in  the  neck  and  shoulders.  The  legs  are  also  weak  and  the  circu- 
lation is  poor.  There  is  sometimes  palpitation  of  the  heart  and 
precordial  distress.  A  certain  amount  of  dyspepsia  is  always  pres- 
ent, and  constipation  is  the  rule.  The  patients  often  have  attacks 
of  vomiting,  and  attempts  to  feed  them  require  much  care.  The 
menstrual  functions  become  irregular.  The  patient  grows  weaker 
and  often  becomes  bedridden,  especially  if  little  attempt  is  made 
to  overcome  the  symptoms  by  voluntary  effort  and  attention  to  nu- 
trition. These  patients  generally  get  well  in  from  one  to  three  years, 
Out  occasionally  they  sink  into  permanent  invalidism.  The  symp- 
toms are  quite  as  much  due  to  mental  sensitiveness  and  disordered 
cerebrum  as  to  any  local  spinal  trouble,  and  the  term  cerebro-spinal 
irritation  is  a  more  correct  one, 

The  Anxiety  Neurosis,  or  Neurasthenia  with  Fixed  Idea. — Some- 
times neurasthenia  is  associated  with  some  single  idea  that  becomes 
fixed  in  the  mind,  and  worries  and  harasses  the  patient  through 
every  moment  of  the  waking  hours.  This  idea  is  always  one  of  a 
depressing  character,  and  usually  one  associated  with  either  remorse 
or  fright.  For  example,  one  patient  of  mine  had  for  one  or  two 
years  an  ordinary  type  of  neurasthenia,  with  a  simple  nervousness, 
depression,  insomnia,  and  cerebral  paresthesia.  After  she  had  been 
well  for  a  few  years  the  trouble  returned,  this  time  with  a  fixed  idea 
that  during  her  early  life  she  had  committed  a  very  wrong  act. 
The  act  itself  was  a  trivial  one,  connected  with  the  taking  of  a  dose 
of  medicine  to  bring  on  her  courses.  But  no  amount  of  assurance 
could  entirely  relieve  her  from  the  distress  caused  by  the  continual 
presence  of  this  remorseful  idea. 


NEURASTHENIA.  533 

In  other  instances  a  patient  will  have  a  neurasthenia  following 
some  severe  domestic  calamity  or  some  shock  or  injury.  Associated 
with  the  general  neurasthenic  symptoms,  may  be  an  intense  fear 
that  she  is  going  to  die  from  some  heart  trouble  and  the  patient  is 
continually  running  to  her  physician,  and  feeling  of  her  pulse,  under 
the  apprehension  that  she  may  drop  dead.  This  condition  is  not 
one,  strictly  speaking,  of  hypochondriasis,  for  the  emotional  dis- 
turbance is  much  stronger  and  more  dominant  than  the  intellectual 
one.  The  patient  quite  appreciates  the  unreasonableness  of  her 
foreboding,  and  in  her  mind  believes  the  assurances  of  her  physician 
that  her  heart  is  perfectly  sound;  but  there  is,  despite  all  this,  a 
distress  which  destroys  her  peace  of  mind  and  makes  her  nervous, 
sleepless,  and  in  every  way  neurasthenic.  Such  patients  do  not 
have  other  symptoms  of  a  melancholia,  although  these  types  of  neu- 
rasthenia are  sometimes  associated  and  appear  to  be  almost  abor- 
tive forms  of  melancholia.  They,  however,  do  not  lose  flesh ;  their 
appetite  may  remain  good,  the  tongue  is  not  coated,  they  have  no 
suicidal  ideas,  nor  do  they  have  the  persistent  insomnia  and  the 
agitation  of  true  melancholia.  Neurasthenics  with  morbid  fears  of 
places  (agoraphobia,  claustrophobia),  of  dirt  (mysophobia),  etc., 
and  neurasthenics  with  the  doubting  mania,  are  not  true  cases  of 
neurasthenia,  but  the  subjects  of  a  psychosis. 

Angiopathic  Neurasthenia. — There  are  some  cases  of  neuras- 
thenia in  which  the  vasomotor  symptoms  are  extremely  prominent. 
I  do  not  refer  now  to  Basedow's  disease,  which  represents  perhaps 
in  a  typical  way  a  vasomotor  neurasthenia,  but  to  certain  cases  in 
which  the  innervation  of  the  blood-vessels  seems  to  be  especially 
impaired.  I  have  given  histories  of  several  cases  of  this  type,  under 
the  head  of  "angiopathic  neurasthenia." 

The  patient  lias  the  general  symptoms  of  neurasthenia,  but  in 
addition  he  has  the  special  symptoms  which  consist  of  a  sense  of 
pulsation  or  beating,  which  involves  the  whole  body.  The  tension 
of  the  pulse  is  low,  the  rate  normal  or  slightly  accelerated.  He 
does  not  have  palpitations  of  the  heart,  as  in  Basedow's  disease, 
and  there  is  no  particular  dyspnoea  on  exertion.  The  skin  usually 
shows  a  striking  degree  of  dermography,  and  there  is  an  epigastric 
pulsation,  as  well  as  pulsation  of  the  carotid. 

Neurasthenia  Gravis. — In  instances  which  are  fortunately  very 
rare  neurasthenia  assumes  a  very  severe  and  serious  type  of  ex- 
haustion. The  patients  suffer  from  the  typical  symptoms  in  much 
the  ordinary  way,  but  the  degree  of  weakness  is  very  much  exag- 
gerated. Such  patients  have  not  only  headaches  and  disturbed 
sleep,  pains  in  the  back  and  paresthesias,  digestive  disturbances,  and 


534  DISEASES   OF   THE   NERVOUS   SYSTEM. 

mental  depression,  but  they  speedily  emaciate  to  a  considerable  ex* 
tent.  They  take  food  in  fair  amounts,  but  it  gives  them  no  strength. 
The  most  careful  applications  of  the  "  rest  cure  "  secure  for  them 
only  temporary  benefit.  They  cannot  walk  far  without  intense  fa- 
tigue and  exhaustion,  with  subsequently  severe  headaches,  or  even 
attacks  of  vomiting  and  diarrhoea.  Despite  closest  examination,  no 
distinct  signs  of  organic  disease  can  be  discovered,  and  I  have  known 
such  patients  to  go  on  into  a  permanent  and  hopeless  invalidism 
which  has  lasted  for  many  years.  In  these  cases  there  is  not  a  hys- 
terical or  even  large  hypochondriacal  element.  No  amount  of  sug- 
gestion or  "  mind  cure"  has  much  effect  upon  them.  They  are  not, 
in  other  words,  hysterical,  bedridden  women,  but  often  men  who 
have  reached  or  passed  the  middle  period  of  life,  and  the  condition 
is  one  suggesting  a  premature  senescence  of  the  nervous  tissues. 

Pathogeny  and  Pathology. — Victims  of  neurasthenia  are  persons 
who  in  all  cases  have  either  inherited  or  acquired  a  nervous  system 
with  lessened  power  of  resistance.  In  the  vast  majority  of  cases  I 
believe  that  inheritance  is  the  cause  of  this  weak  nerve  structure. 
Such  inheritance  may  be  very  slight,  and,  if  the  patient  lives  with 
reasonable  care,  he  has  good  health  and  lives  to  an  old  age.  Under 
the  influence  of  severe  and  depressing  agencies,  or  of  poisons  or 
infections,  however,  this  resisting  power  of  the  nerve  cells  is 
weakened.  The  person  then  is  ripe  for  an  attack  of  nervous  ex- 
haustion. 

It  seems  probable  that  an  inherited  tuberculous  taint  in  a  meas- 
ure prepares  the  system  for  nervous  prostration.  Among  acquired 
diseases  syphilis  undoubtedly  impairs  the  physical  strength  and 
makes  the  person  predisposed  to  neurasthenia.  So,  I  believe,  does 
excessive  indulgence  in  alcohol,  tea,  and  tobacco,  and  I  would  add 
an  extreme  indulgence  in  the  carbohydrates,  such  as  candies,  sweets, 
and  pastries,  of  all  kinds,  when  taken  continuously  in  excess  of  a 
normal  ratio. 

Dr.  C.  F.  Hodge  has  shown  that  when  the  nerve  cells  are  fa- 
tigued by  persistent  work  or  electrical  stimulation,  the  nucleus  of 
the  cells  decreases  in  size,  has  a  jagged,  irregular  outline,  loses  its 
open  and  reticulated  appearance,  and  takes  a  darker  stain — that 
the  cell  protoplasm  shrinks  slightly  in  size  and  stains  more  feebly. 
It  is  a  fair  inference  that  human  beings  who  continually  and  for  a 
long  time  fatigue  their  nervous  system  finally  get  their  cells  into 
a  like  state  and  so  disorganize  them  that  they  are  no  longer  repaired 
properly ;  cell  bodies  and  nuclei  become  permanently  shrunken  and 
lose  their  normal  anatomical  structure.  This  view  explains  certain 
forms  of  neurasthenia  that  come  on  gradually  as  the  result  of  per- 


NEURASTHENIA.  .  535 

sistent  overwork  or  abuse  of  the  nervous  system,  with  bad  feeding 
and  stimulation. 

A  considerable  number  of  cases,  however,  including  most  of  the 
traumatic  forms  of  neurasthenia,  come  on  suddenly  as  the  result 
of  a  single  severe  shock.  Here  we  must  invoke  some  other  agency, 
and  this  I  take  to  be  the  vascular  system.  Under  the  influence 
of  intense  and  sudden  emotions  of  the  depressing  kind,  the  vaso- 
motor centre  and  the  whole  vascular  mechanism  go  through  a  kind 
of  convulsion,  and  this  convulsive  disturbance  is  a  thing  which  the 
vasomotor  system  of  those  predisposed  to  neurasthenia  is  unable  to 
withstand.  The  nerve  cells  connected  with  it  are  so  weakened  in 
their  nutritive  and  functional  power  that  the  blood  is  not  carried 
regularly  and  normally  to  the  nerve  centres  in  the  way  to  which  such 
centres  have  been  accustomed;  hence  the  nerve  cells  become  im- 
paired in  nutrition  and  functionating  power. 

Another  factor  undoubtedly  exists  in  the  production  of  neuras- 
thenia, and  that  is  the  irritation  of  the  nerve  centres  by  poisons 
generated  within  the  body.  We  know  that  in  certain  forms  of  di- 
gestive disorder  poisons  are  probably  absorbed  into  the  blood,  and 
we  know  also  that  in  gout}'  and  lithaemic  states  the  uric  acid  and 
other  products  of  defective  metabolism  poison  the  system  and  in- 
duce many  of  the  symptoms  of  neurasthenia.  There  is,  therefore, 
this  element  of  autotoxeemia  which  enters  measurably  into  the 
production  of  neurasthenia.  The  subject,  however,  has  yet  to  be 
worked  out  into  definite  shape.  When  a  person  has  suffered  from 
neurasthenia  for  a  considerable  time,  there  are,  no  doubt,  cer- 
tain more  or  less  permanent  changes  in  the  body ;  at  least  we  note 
that  catarrhal  conditions  of  the  stomach  and  bowels  may  become 
permanent,  and  that  anamiia  may  be  present.  In  cases  occurring 
in  persons  advanced  in  life,  arterial  changes  become  more  rapidly 
pronounced  than  in  healthy  persons.  In  fact,  a  prolonged  neuras- 
thenia, with  the  accompanying  worry  and  mental  depression,  no 
doubt  hastens  and  accentuates  degenerative  vascular  changes.  ]  Vi- 
ctim has  suggested  the  name  "terminal  neurasthenia"  for  that 
condition  of  chronic  nerve  exhaustion  in  which  anatomical  changes 
have  become  fixed. 

Diagnosis.  Neurasthenia  is  to  be  differentiated  from  the  fol- 
lowing conditions:  hysteria,  major  and  minor;  hypochondriasis; 
melancholia;  the  beginning  stage  of  general  paresis;  simulation; 
the  reflex  effects  of  some  gross  bodily  disease. 

Hysteria  major  is  distinguished  by  the  presence  of  the  stigmata 
of  that  condition  and  the  periodical  crises  which  occur.  In  the 
ordinary  or  minor  forms  of  hysteria  the  patient  does  not  suffer  from 


536  DISEASES    OF   THE    NERVOUS    SYSTEM. 

any  of  the  classical  symptoms  of  neurasthenia;  she  often  sleeps 
well,  has  no  persistent  headaches,  has  a  good  appetite,  and  has 
none  of  the  characteristic  paraesthesias  and  cephalic  sensations; 
she  is  mentally  active  and  alert,  and  often  gay  and  cheerful,  and 
is  physically  strong.  The  neurasthenic,  on  the  other  hand,  is  gen- 
erally depressed  and  serious  and  greatly  concerned  in  regard  to  her 
condition.  She  is  docile  and  quite  willing  to  do  everything  possible 
to  get  well.  She  has  no  severe  emotional  crises,  and  none  of  the 
globus  or  the  clavus  pains.  Hysteria  minor  may  be  associated  with 
neurasthenia,  and  in  women  this  is  not  infrequently  the  case.  The 
Trench  have  for  this  combination  the  term  "hystero-neurasthenia." 

In  hypochondriasis  the  patient  suffers  from  a  purely  mental 
malady.  There  is  almost  always  a  history  of  hereditary  taint,  and 
the  patient  himself  usually  shows  somatic  signs  of  degeneration. 
He  has  few  of  the  stigmata  of  neurasthenia,  and  is  mainly  occupied 
with  a  fixed  idea  concerning  some  special  bodily  ailment.  It  is  this 
isolation  of  mental  symptoms,  the  hereditary  taint,  and  this  very 
marked  evidence  of  the  purely  psychic  disturbance  which  set  off 
hypochondria,  as  at  present  understood,  from  a  neurasthenia.  Hy- 
pochondriacs, it  may  be  added,  are  bodily  well  or  at  least  are  able 
to  undertake  physical  exertions,  which  neurasthenics  cannot  do. 
Here,  again,  however,  it  must  be  borne  in  mind  that  a  person 
starting  with  neurasthenia  may  finally  end  up  with  a  form  of  hypo- 
chondriasis;  that  is  to  say,  he  may  be  practically  cured  of  the  as- 
thenic symptoms,  but  his  mind  has  become  disturbed  by  his  painful 
experience,  and  he  settles  down  into  a  mild  grade  of  hypochon- 
driasis. 

The  early  stages  of  mild  forms  of  melancholia  simulate  neuras- 
thenia. This  is  so  much  the  case  that  some  authors  have  described 
neurasthenia  as  an  abortive  form  of  melancholia.  We  have  already 
referred  to  this  under  the  head  of  "neurasthenia  with  fixed  ideas," 
and  we  there  pointed  out  some  of  the  distinguishing  points  which 
enable  one  to  recognize  melancholia.  The  loss  of  flesh,  persistent 
loss  of  sleep,  rapid  pulse,  motor  restlessness,  and  extreme  mental 
depression,  with  delusions  and  suicidal  ideas,  are  the  signs  which 
enable  one  with  very  little  difficulty  to  distinguish  melancholia. 
This  latter  disease,  also,  is  found  to  simulate  neurasthenia  mainly 
in  women  who  are  approaching  the  climacteric. 

In  the  early  stages  of  general  paresis  the  patients  suffer  from 
neurasthenic  symptoms.  They  find  that  they  are  no  longer  able  to 
work  as  they  did  before,  their  sleep  is  disturbed,  they  are  excited, 
forgetful,  and  nervous.  They  have  not  yet  developed  many  of  the 
physical  symptoms  perhaps;  hence  their  condition  suggests  and  is 


NEURASTHENIA.  537 

often  mistaken  for  a  simple  nervous  breakdown.  The  condition  is 
much  more  perfectly  simulated  when  the  patient  has  been  taking  a 
good  deal  of  stimulation,  in  order  to  keep  himself  up  to  the  mark. 
A  careful  examination,  however,  soon  reveals  the  true  nature  of  the 
trouble.  Even  in  the  early  stages  of  paresis  some  evidence  of  fail- 
ure of  memory  and  of  the  power  to  write  and  spell  correctly,  with 
expansiveness  of  ideas,  will  be  found.  Besides  this,  a  physical  ex- 
amination will  show  extreme  tremor  of  the  hands,  tremor  of  the  face 
and  tongue,  and  exaggerated  reflexes.  The  pupils  also  will  often 
be  found  to  be  unequal.  It  is  true  that  facial  tremor,  tongue  tremor, 
and  unequal  pupils  occur  in  neurasthenia,  but  they  are  rare  and 
not  so  marked. 

A  patient  may  be  suffering  from  a  number  of  bodily  ailments, 
and  if  this  person  be  at  the  same  time  of  a  somewhat  nervous  con- 
stitution the  condition  may  resemble  neurasthenia.  Those  persons 
having  a  very  feeble  digestion,  with  dilated  stomach  and  an  atonic 
condition  of  the  alimentary  tract,  may  get  depressed,  fretful,  and 
sleepless ;  so  a  person  suffering  from  some  chronic  uterine  or  ovarian 
or  bladder  trouble  may  present  many  symptoms  of  nervous  irrita- 
tion. It  must  depend  largely  upon  the  good  sense  of  the  physician 
to  measure  the  importance  of  the  local  troubles  as  compared  with 
those  of  the  general  symptoms.  I  believe  that  the  fully  developed 
type  of  neurasthenia  is  rarely  brought  out  by  local  disease  alone. 
Still,  I  have  seen  cases  with  neurasthenic  symptoms  cured  for  a 
time  by  washing  out  the  stomach,  and  enormous  relief  to  the  ner- 
vous irritation  to  result  from  treating  the  condition  of  the  blood  or 
relieving  the  uterine  disturbances. 

Course  and  Prognosis. — There  is  such  a  thing  as  acute  neuras- 
thenia. This  follows  prolonged  debauches  and  long  periods  of  ex- 
cessive mental  strain,  with  loss  of  sleep.  Such  patients  may  pre- 
sent all  the  signs  of  neurasthenia,  and  get  perfectly  well  in  two  or 
three  weeks.  Neurasthenia,  however,  is  essentially  a  chronic  dis- 
ease, and  when  speaking  of  it  we  refer  to  this  type  of  the  disorder. 
It  is  a  disease  which  comes  on  as  a  rule  gradually,  developing, 
however,  in  the  course  of  a  few  months.  It  may,  however,  come  on 
suddenly  after  shocks  and  accidents,  and  it  may  develop  or  follow 
rapidly  after  an  acute  infectious  fever.  It  always  reaches  its  height 
in  a  comparatively  short  time,  and  runs  a  course  lasting  from  one  or 
two  to  seven  or  eight  years.  This  course  is  a  varying  one,  and  this 
variation  is  particularly  noticeable  when  the  patient  begins  to  get 
well.  The  patient  continues  to  improve  for  a  time  and  then  sud- 
denly falls  back,  then  goes  forward  again,  and  thus  convalescence 
progresses.      Complete  restoration  to  health  is  possible  and   fre- 


538  DISEASES   OF   THE    NERVOUS   SYSTEM. 

quent,  but  the  patient  always  has  to  take  more  care  of  himself 
than  before.  As  a  result  of  an  attack  of  neurasthenia,  men  and 
women  who  have  suffered  from  it  are  apt  thereafter  to  lead  very 
saint-like  and  ascetic  lives,  and  hence  they  as  a  rule  live  long.  It 
used  to  be  said  by  Dr.  Beard  that  neurasthenics  would  have  a  long 
and  happy  old  age.  They  pass  through  the  valley  of  the  shadow 
of  death,  but  the  experience  may  be  a  profitable,  if  not  a  pleasant 
one. 

Treatment. — Naturally,  the  measure  of  leading  importance  in  the 
treatment  of  neurasthenia  is  rest,  and  the  problem  of  how  this  can 
be  obtained  is  the  first  one  to  confront  the  physician. 

In  the  severe  t}'pes  of  hystero-neurasthenia,  especially  when  it 
occurs  in  young  women,  the  application  of  the  "rest  cure,"  which 
has  been  so  ingeniously  elaborated  and  perfected  by  Dr.  Weir 
Mitchell,  is  undoubtedly  the  best  treatment.  I  do  not  find,  how- 
ever, that  men  submit  themselves  readily  to  this  measure,  and  it 
seems  to  me  to  answer  best  for  those  neurasthenic  women  who  suffer 
also  from  some  hysteria  and  who  are  reasonably  "  suggestible"  pa- 
tients. A  modified  rest  cure  can  often  be  secured  by  making  the 
patient  stay  in  bed  until  after  midday  lunch  or  lie  down  for  an  hour 
after  each  meal,  and  go  to  bed  early  in  the  evening.  Business  men 
will  often  cut  their  business  hours  down  one-half  if  they  are  allowed 
still  to  continue  some  work.  I  do  not  believe,  however,  that  the 
physician  should  often  use  half-way  measures,  and  it  is  best  to  im- 
press at  once  upon  the  patients  the  fact  that  nothing  is  of  so  much 
importance  to  them  as  to  get  well,  and  to  get  so  that  they  can  take 
their  place  at  their  work  again.  Change  of  scene  is  usually  very 
beneficial  to  neurasthenics,  but  travelling  is  injurious  to  them. 
They  should  be  sent  to  some  special  place  and  be  made  to  stay 
there.  A  tour -along  the  Mediterranean  coast  or  a  trip  to  Europe 
often  brings  them  back  worse  than  when  they  went.  Much  the 
same  can  be  said  of  trips  to  various  places  in  the  South  or  West. 
Some  of  the  sanitaria  in  Germany,  some  of  the  places  in  the  Riviera, 
Egypt  and  Bermuda,  Nantucket,  parts  of  North  and  South  Carolina 
and  Arizona,  furnish  good  resorts  for  neurasthenics.  They  generally 
do  better  in  the  mountains,  if  the  altitude  is  not  too  high,  than  they 
do  by  the  seashore.  Dry,  windy,  sunny  climates  like  those  of  the 
Colorado  plateau  and  parts  of  California  and  the  Northwestern 
States  are  too  stimulating  for  most  cases. 

Much  good  may  be  obtained  at  the  numerous  sanitaria  which 
exist  in  this  country.  Many  of  these  are  well  conducted  and  well 
supplied  with  all  the  modern  appliances  for  treatment.  It  is,  how- 
ever, always  a  serious  thing  to  send  a  neurasthenic  to  a  sanitarium, 


NEURASTHENIA.  539 

for  the  reason  that  if  he  stays  there  too  long  he  becomes  contami- 
nated with  the  atmosphere  of  invalidism  about  these  places  and  de- 
velops hypochondriacal  ideas  as  to  his  diet,  his  liver,  his  stomach, 
his  sleeplessness,  and  his  various  sensory  disturbances.  In  sending 
a  patient  to  a  sanitarium,  it  is  a  wise  plan  to  tell  him  not  to  stay, 
under  any  consideration,  longer  than  six  weeks;  usually  four  is  bet- 
ter. In  the  summer  time  great  benefit  can  be  secured  by  camping 
out  in  the  woods  and  living  a  purely  outdoor  life,  away  from  all  the 
conventionalities  and  restraints  of  civilization. 

The  diet  of  neurasthenics,  according  to  the  views  of  most  Amer- 
ican physicians,  should  be  chiefly  a  nitrogenous  one,  and  my  direc- 
tions are  that  the  patient  can  eat  meats,  fish,  eggs,  green  vegetables, 
and  fruits.  Milk  can  almost  always  be  taken,  at  least  for  a  short 
time.  There  is  a  certain  class  of  lithaeinic  patients  who  do  best 
upon  milk,  vegetables,  and  fruit,  with  practically  no  meat;  these, 
however,  are  in  the  minority.  In  general,  tea  aud  coffee,  alcohol 
and  tobacco,  are  to  be  entirely  prohibited,  but  this  is  not  an  abso- 
lute rule.  In  some  cases  coffee  is  beneficial,  in  some  tea  does  no 
harm,  and  in  others  a  small  amount  of  whiskey  or  dry  wine  and  a 
cigar  are  also  harmless.  The  physician  has  to  determine  this  by 
the  reactions  and  habits  of  the  patient.  Neurasthenics  usually 
drink  too  little  water  and  it  is  wise  to  prescribe  a  certain  amount 
for  them.  Four  or  five  glasses  of  water,  which  may  be  either  plain 
or  alkalinized,  are  to  be  taken  daily.  I  find  no  special  advantage 
in  the  various  much  advertised  lithia  and  spring  waters.  In  dys- 
peptic patients  the  meals  should  be  small  in  amount  and  taken  at 
frequent  intervals;  three  light  regular  meals  a  day  and  a  little  food 
in  between  form  a  regimen  which  usually  answers  well. 

Hydrotherapy,  electricity,  and  massage  are  all  measures  which 
prove  of  service  to  the  neurasthenic.  Of  these,  hydrotherapy  is 
the  most  useful,  though  its  value  can  be  overestimated.  The  ordi- 
nary prescriptions  consist  in  the  cold  sponge  bath  every  morning, 
and,  if  it  is  practicable,  the  use  of  a  Charcot  or  a  Scottish  douche 
every  other  day.  For  women  wet  packs  with  massage  are  sometimes 
helpful,  particularly  in  cases  in  which  there  are  a  great  deal  of  ner- 
vousness and  motor  irritation.  At  night  a  lukewarm  bath,  at  a 
temperature  of  95  ,  for  ten  minutes,  sometimes  relieves  the  pares- 
thesia and  sleeplessness. 

Massage  seems  to  me  of  not  very  much  use  in  men,  but  it  is 
often  grateful  and  helpful  to  women,  and  when  a  great  deal  of  rest 
is  to  be  enforced  it  is  essential  to  employ  it  for  both  sexes. 

Physical  exercise  is  an  agent  of  enormous  value  in  neurasthenia, 
and  the  advent  of  the  bicycle  has  done  a  vast  deal  of  good  in  reliov- 


540  DISEASES    OF   THE   NERVOUS   SYSTEM. 

ing  this  condition.  Horseback  riding  is  probably  just  as  efficient, 
but  much  less  practical.  Many  persons  are  greatly  wedded  to  the 
exercise  of  walking,  and  it  seems  best  to  fit  their  needs.  It  is, 
however,  a  kind  of  exercise  which  does  not  take  the  patient's  mind 
off  himself,  and  does  not  develop  the  respiratory  functions  so  well 
as  other  measures  do.  Golfing  fills  in  this  lack,  and  this  sport  will 
doubtless  be  of  service  in  neurasthenia. 

The  drugs  of  most  value  are  the  bromides,  nux  vomica,  mineral 
acids,  quinine,  iron,  valerian,  the  coal-tar  antineuralgics,  the  hyp- 
notics, and  saline  and  akaline  laxatives,  and  salicylates. 

The  bromide  of  sodium  or  potassium  should  be  given  in  small 
doses ;  it  should  be  kept  up  for  a  limited  time  and  then  gradually 
reduced.  At  the  same  time  or  later  the  patient  may  be  given  a 
tonic  mixture  containing  such  drugs  as  the  symptoms  suggest. 
Quinine  must  be  given  carefully,  as  it  causes  increase  of  nervousness 
in  many. 

Phosphoric  and  muriatic  acids  are  the  two  mineral  acids  most 
often  of  use.  These  acids  are  usually  better  given  after  meals. 
The  saccharated  carbonate  of  iron  or  Blaud's  pills,  if  given,  should 
be  given  generously,  i.e.,  in  doses  of  thirty  grains  daily.  The  best 
preparations  of  iron  are  the  tartrate  of  iron  and  potassium,  the  car- 
bonate, the  citrate,  and  the  tincture.  I  find  no  special  benefit  from 
the  albuminate  or  the  peptonized  preparations. 

The  foregoing  covers  in  a  general  way  the  measures  to  be  used 
in  treating  neurasthenics.  The  physician  must  seek  to  secure  the 
complete  confidence  and  docility  of  his  patient.  He  then  uses  meas- 
ures which  secure  some  bodily  and  much  mental  rest.  He  gives  to 
him  simple  and  nourishing  food  in  no  excess,  and  prescribes  meas- 
ures which  restore  the  slo wed-up  or  perverted  metabolism. 

The  Sexual  Neuroses  axd  Psychoses. 

Of  the  above  disorders  the  neurologist  has  to  deal  chiefly  with 
the  vicious  habits  of  masturbation  (which  majr,  however,  be  also  a 
manifestation  of  disease)  and  the  sexual  neuroses,  spermatorrhoea 
and  impotence. 

Masturbation  axd  Spermatorrhea. — Masturbation  is  the 
name  given  to  the  vicious  habit  of  artifically  exciting  the  sexual 
organs.  It  is  very  common  among  boys  and  less  common  but  pres- 
ent among  girls  and  adult  men  and  women.  It  is  usually  only  a 
vice  due  originally  to  low  associations  and  teachings  among  chil- 
dren. In  some  cases  it  is  a  disease  or  the  symptom  of  a  neurotic 
or  insane  constitution. 


THE    SEXUAL    NEUKOSES.  541 

Etiology. — It  is  most  common  between  the  ages  of  fourteen  and 
eighteen,  but  may  begin  earlier.  Even  infants  and  very  young  chil- 
dren sometimes  masturbate,  usually  as  the  result  of  some  local  irri- 
tation which  leads  them  to  rub  the  genitals.  A  tight  prepuce,  ec- 
zema, or  worms  may  lead  to  the  habit,  but  it  is  usually  taught  by 
a  companion.  The  practice  sometimes  attacks  schools  almost  like 
an  epidemic,  for  in  every  institution  a  certain  per  cent  of  the  boys 
are  sexually  precocious  or  vicious,  while  the  others  are  ignorant  and 
innocent  of  the  evils  of  the  practice.  Masturbation  is  relatively 
rare  after  twenty,  but  is  practised  by  some  throughout  life  even  up 
to  old  age. 

Results. — Masturbation  as  ordinarily  practised  leads  after  a 
time  to  a  feeling  of  malaise,  mental  depression,  disinclination  to 
work,  study,  or  to  enjoy  one's  self  as  before.  The  appetite  is  a 
little  impaired,  the  extremities  easily  get  cold  and  perspire  readily. 
Peculiar  numb  feelings  are  felt  in  the  hands  and  feet.  There  are 
an  unnatural  nervousness  and  irritability,  and  the  power  of  concen- 
trating the  mind  is  a  little  weakened.  The  patients  often  have  di- 
lated pupils  and  hyperaesthetic  skin.  After  a  time  nocturnal  emis- 
sions occur.  The  organs  become  irritable  and  slight  excitement 
causes  erections.  These  symptoms  may  be  slightly  marked  and 
pass  away  in  a  day  or  two,  or  until  another  indulgence  occurs. 

Masturbation  is  sometimes  done  to  an  extraordinary  extent,  even 
daily  or  twice  daily  for  a  considerable  time.  After  a  while  the 
young  man  begins  to  find  that  he  is  not  well  and  realizes  that  this 
habit  is  hurting  him.  Then  if  he  be  sensible  and  of  healthy  con- 
stitution he  stops.  Others  are  frightened  out  of  it  by  friends  or  by 
reading  the  terrorizing  stories  printed  in  quack  advertisements  and 
circulars.  Sometimes  the  fright  thus  caused  leads  the  unhappy 
youth  into  a  condition  of  hypochondriasis,  which  is  helped  on  by 
the  occurrence  of  nocturnal  pollutions  and  the  nervous  debility  re- 
sulting from  his  past  indiscretions.  In  other  cases  in  which  there 
is  a  decided  neurotic  history,  a  genuine  neurasthenia  of  a  sexual 
type  develops  and  annoys  the  patient  for  years. 

.Masturbation  rarely  leads  to  insanity  and  is  oftener  a  symptom 
than  a  cause  of  such  disorder.  It  is  occasionally  the  cause  of  epi- 
lepsy.  When  this  is  the  case  the  convulsive  attacks  are  likely  to 
put  on  a  hy steroid  phase  and  are  accompanied  by  peculiar  co-ordi- 
nated convulsions  and  emotional  disturbance.  Masturbation  is  the 
common  cause  of  hystero-epilepsy  in  women, 

Diagnosis.— Many  victims  of  the  masturbation  habit  who  have 
come  to  recognize  its  evils  and  tried  to  stop  it  develop  a  hypochon- 
driacal condition,  and  feel  sure  that  there  is  something  in  their  faces 


542  DISEASES   OF  THE  NERVOUS   SYSTEM. 

which  reveals  to  the  world  their  trouble.  This  is  not  the  case.  But 
there  is  a  certain  physiognomy  which  in  a  measure  characterizes  the 
masturbator  to  such  an  extent  that  an  experienced  observer  can  de- 
tect it.  The  pale,  pasty  complexion,  moist,  furtive  eye,  dilated  pu- 
pil, listless,  restless,  and  depressed  manner,  the  wet,  flabby  palms, 
and  hyperaesthetic  skin,  all  help  to  tell  the  story.  Locally  the  penis 
is  often  reddened  and  more  or  less  turgid,  the  scrotum  relaxed,  and 
a  varicocele  may  be  present.  Examination  of  the  urine  may  reveal 
spermatozoa.  The  urine  also  is  almost  always  of  rather  low  specific 
gravity,  and  contains  a  great  excess  of  phosphates,  both  earthy  and 
alkaline. 

Treatment. — The  patient  must  be  told  plainly  the  necessity  of 
stopping  the  practice.  He  must  be  impressed,  but  not  terrorized. 
He  should  be  kept  out  of  doors  at  vigorous  physical  exercise,  for 
sedentary  and  solitary  work  is  always  bad  for  such  cases.  He 
should  be  made  to  take  cold-water  baths  and  should  sleep  on  a  hard 
bed  with  light  covering.  He  had  better  sleep  with  some  one  whose 
presence  may  exercise  a  controlling  influence.  He  should  not  eat 
heartily  at  night,  never  just  before  going  to  bed,  and  what  is  still 
more  important,  he  should  not  drink  before  going  to  bed.  Some- 
times it  is  well  to  have  him  wakened  at  an  early  hour  in  the  morn- 
ing, when  he  should  empty  his  bladder ;  for  emissions  occur  often 
early  in  the  morning  and  are  promoted  by  the  irritation  of  a  full 
bladder. 

Locally  cold-steel  sounds  may  be  introduced  and  allowed  to  re- 
main for  ten  minutes  three  or  more  times  a  week,  or  the  psychophor 
or  Ultzmann'  s  short  catheter  may  be  used.  In  bad  cases  with  a  great 
deal  of  prostatic  irritation,  local  applications  of  nitrate  of  silver  are 
needed.  Internally  a  mixture  of  tinct.  opii,  tinct.  camph.,  and  tinct. 
lupulin  may  be  given  at  night,  the  ingredients  being  somewhat  va- 
ried in  amount  to  suit  the  case.  Bromides,  chloral,  atropine,  and  salix 
nigra  are  also  drugs  which  are  often  useful.  The  mechanical  meas- 
ures which  have  been  devised  for  preventing  erections,  such  as  rings 
with  sharp  teeth,  are  rarely  needed  and  rarely  useful.  They  may 
even  do  harm  by  directing  the  mind  to  the  affected  function. 

I  do  not  believe  it  right  for  the  physician  to  prescribe  fornica- 
tion. It  is  not  safe  nor  curative,  apart  from  the  moral  aspect  of  the 
matter.  It  has  always  struck  me  also  as  pretty  small  business  for 
a  man  purposely  to  select  a  wife  to  relieve  him  of  the  results  of  a 
weak  will  and  vicious  sensual  indulgence.  If  marriage  comes  in 
the  natural  course  of  events,  as  it  often  does,  so  much  the  better. 
But  to  select  a  wife  as  a  remedial  agent  for  masturbation  is  unjust 
to  the  woman  and  a  confession  of  moral  and  mental  feebleness. 


TRAUMATIC   NEUROSES.  543 

Man  is  distinguished  from  the  brute  by  his  self-control.  Let  him 
bear  this  fact  in  mind  and  raise  himself  above  the  animals  by  a  de- 
termined effort  of  the  will.  Pure  thoughts  and  chaste  associations, 
vigorous  physical  exercise,  and  a  resolute  effort  to  act  a  manly  part 
will  always  be  successful. 

Traumatic   Nervous   Affections   (Traumatic  Neuroses   and 
Psychoses,  Spinal  Concussion). 

The  present  tendency  of  neurology  is  to  deny  the  existence  of 
any  special  nervous  affection  produced  by  trauma  or  shock.  There 
may  follow  from  these  causes: 

1.  Surgical  injuries. 

2.  Neurasthenic  states. 

3.  Hysterical  states. 

4.  Hemorrhagic,  inflammatory,  and  degenerative  diseases. 

5.  Combinations  of  the  foregoing. 

These  troubles  may  follow  not  only  railway  but  other  injuries, 
but  are  especially  liable  to  follow  those  associated  with  intense 
fright. 

2.  Traumatic  neurasthenia,  or  "traumatic  neurosis,"  "railway 
spine, "  does  not  differ  from  forms  of  neurasthenia  produced  by  other 
causes,  except  that  with  it  there  may  be  certain  sprains  and  surgical 
troubles.  Its  special  symptoms  are  described  under  the  head  of 
neurasthenia. 

3.  Traumatic  hysteria  is  a  rare  affection  in  this  country.  It 
does  not  differ  from  hysteria  produced  by  other  causes,  except  for 
its  sudden  onset  and  occasional  surgical  complications.  It  is  usu- 
ally a  hysteria  major  and  has  the  characteristic  stigmata  of  that 
type.  In  this  city  electrical  injuries  and  frights  have  produced 
some  classical  cases  of  hysteria  major. 

4.  There  is  considerable  evidence  that  in  some  rare  cases  trau- 
matism may  produce  minute  multiple  hemorrhages  throughout  the 
nervous  centres.  In  such  cases  there  are  usually  neurasthenic  or 
hysterical  symptoms  and  in  addition  symptoms  of  organic  disease. 

In  the  majority  of  cases  the  symptom  complex  is  something  like 
this  (Knapp):  "The  patient  has  headache  and  vertigo;  he  is  de- 
pressed, iritable,  and  hypochondriacal,  with  a  diminished  power  of 
a] >pli ration;  he  may  have  some  visual  disturbance;  he  often  has  a 
contracted  field  of  vision  and  occasionally  optic  atrophy ;  there  is 
some  tremor  and  perhaps  inco-ordination ;  he  has  anaesthesia,  usu- 
ally not  limited  to  one-half  of  the  body,  and  with  it  numbness  and 
prickling;  his  movements  are  slow  and  weak;  his  tendon  reflexes 


514  DISEASES   OF   THE   NERVOUS   SYSTEM. 

are  exaggerated ;  there  is  often  some  lack  of  control  over  his  blad- 
der; and  he  may  have  pain  and  stiffness  in  the  back  from  muscular 
strain."  The  symptoms  eventually  resemble  a  disseminated  scle- 
rosis. 

Massive  hemorrhages  and  serious  mechanical  injury  of  the  ner- 
vous centres  may  be  also  produced  by  injury. 

Finally,  it  is  a  well-known  fact  that  traumatisms  may  excite  in 
the  predisposed  locomotor  ataxia,  inebriety,  insanity,  or  may  lead 
to  the  development  of  a  cerebral  tumor. 

It  is  the  mental  impression,  the  shock,  much  more  than  the 
physical  injury,  which  produces  the  functional  neurosis  or  psy- 
chosis. 

The  symptoms  may  appear  soon  after  the  accident,  or  after  a 
period  of  relative  health  lasting  some  weeks  the  neurosis  gradually 
develops. 

The  most  important  practical  point  in  connection  with  the  sub- 
ject is  the  diagnosis  and  the  elimination  of  malingering.  This  is 
additionally  difficult  for  the  reason  that  the  hopes  and  anxieties  de- 
pending upon  litigation  tend  to  cause  introspection,  exaggeration  of 
symptoms,  and  unconscious  bias  even  in  the  most  honest.  The  opin- 
ion among  American  neurologists  tends  to  favor  the  seriousness  of 
traumatic  neuroses.  While  malingering  is  not  rare,  yet  if  the  patient 
has  really  a  traumatic  neurasthenia  or  hysteria  the  disease  may  not 
be  a  trifling  one.  Careful  research,  however,  often  tends  to  elicit 
the  fact  that  previous  to  the  injury  the  patient  was  an  alcoholic, 
syphilitic,  or  neurotic,  and  perhaps  had  already  the  beginnings  of 
his  alleged  traumatic  disorder.  In  no  part  of  clinical  medicine  is  a 
careful  and  searching  examination  and  weighing  of  symptoms  more 
urgently  called  for.  The  methods  of  carrying  out  such  examina- 
tions are  given  elsewhere.  Special  methods  for  testing  anaesthesia 
are  sometimes  needed.  The  two  sides  of  the  body  should  be  tested 
simultaneously  with  concealed  needles,  beginning  on  the  trunk,  or 
the  faradic  current  with  a  double-pointed  electrode  may  be  used. 
There  are  few  patients  who  can  successfully  deceive  in  an  examina- 
tion covering  all  the  special  senses. 

The  treatment  of  the  neuroses  calls  for  no  special  notice. 

Exophthalmic  Goitre  (Basedow's  Disease,  Graves'  Disease). 

Exophthalmic  goitre  is  a  chronic  glandular  neurosis  characterized 
by  rapid  heart  beat,  enlargement  of  the  thyroid  gland,  protrusion 
of  the  eyeballs,  and  various  neurasthenic  and  vasomotor  symptoms 

Etiology. — The  disease  occurs  much  oftener  in  women  than  men 


EXOPHTHALMIC    GOITRE.  545 

(four  to  one).  It  is  a  disease  of  early  adult  life,  occurring  chiefly 
between  fifteen  and  thirty -five,  very  rarely  in  childhood,  and  never 
after  fifty.*  It  is  apparently  more  common  in  the  Anglo-Saxon 
race,  but  is  not  very  frequent  in  America,  at  least  in  the  Eastern 
States.  I  am  informed  that  it  is  rather  common  in  the  Northern 
Central  States.  There  is  very  rarely  any  direct  inheritance  of  the 
disease,  but  the  family  is  often  a  neuropathic  one.  As  a  rule,  the 
patient  is  of  a  neurotic  temperament.  Anaemia  and  debilitating 
diseases  promote  its  development.  Goitre  and  heart  disease  do  not 
seem  to  predispose  to  it.  The  most  frequent  exciting  causes  are 
powerful  depressing  emotions  and  severe  physical  exertion.  Rarer 
causes  are  injuries  and  infectious  diseases,  such  as  measles,  scarlet 
fever,  and  pneumonia. 

Symptom* — The  disease  usually  begins  gradually  and  the  first 
symptom  is  in  most  cases  rapid  heart  beat  and  palpitations,  accom- 
panied with  some  nervousness  and  tremor.  The  next  symptom  is 
enlargement  of  the  thyroid  gland,  and  at  about  the  same  time  the 
eyeballs  begin  to  protrude.  This  order  of  development  does  not 
always  take  place,  and  occasionally  one  of  the  three  principal  symp- 
toms is  not  present.  The  disease  is  usually  one  or  two  years  in  de- 
veloping, the  heart  symptoms  being  those  which  continue  by  them- 
selves longest.  With  the  symptoms  mentioned  there  occur  many 
minor  troubles  which  are.  more  or  less  characteristic.  The  patient 
is  usually  very  nervous  and  irritable;  a  distressing  insomnia  may 
be  present.  There  is  almost  uniformly  a  fine  tremor  (eight  to  nine 
per  second)  of  the  hands,  less  marked  in  the  lower  limbs  and  not 
present  in  the  face  or  tongue.  The  reflexes  are  exaggerated. 
There  is  a  tendency  at  times  in  walking  for  the  knees  suddenly  to 
give  way.  The  patient  rarely  has  neuralgias,  but  does  have  burn- 
ing or  feverish  sensations  and  headaches.  The  skin  is  rather  red- 
1  and  the  patient  sweats  profusely.  Pigmentation  and  vitiligo 
are  sometimes  seen,  and  urticaria  may  develop.  The  electrical  re- 
sistance of  the  body  is  much  diminished,  being  800  to  1,500  (/Inns 
instead  of  2,000  to  3,000.  There  is  sometimes  a  demographic  skin, 
as  in  other  neurasthenic  states.  The  respiratory  function  is  weak- 
ened and  chest  expansion  often  falls  below  one  inch  (Fiske-Bryson>). 
Attacks  of  a  persistent  watery  diarrhoea  occur.  Anaemia  is  usually 
present.  There  is  occasionally  polyuria,  more  rarely  glycosuria. 
The  menses  are  irregular  and  amenorrhea  often  exists.  A  slight 
rise  in  temperature  may  occur. 

*  Among  33  cases  at  the  New  York  Post-Graduate  Clinic  (Fiske-Brysen) 
there  were  8  males,  2.*» females.     Ages:  thirteen  to  twenty,  8;  twenty-one  to 
thirty,  8  ;  thirtv-one  to  forty,  6  ;  forty -one  to  fifty,  B  ;  fifty-one  to  sixtv,  1. 
35  * 


546  DISEASES   OF   THE   NERVOUS   SYSTEM. 

The  major  symptoms  of  the  disease  are : 

Tachycardia  and  pulsating  arteries. 

Goitre. 

Exophthalmus. 

Tremor. 
The  minor  symptoms  are : 

Nervousness. 

Sweating. 

Insomnia. 

Lessened  electrical  resistance. 

Subjective  sensations  of  heat. 

Diarrhoea. 

Polyuria. 
Symptoms  in  Detail. — Tachycardia  is  the  most  constant  single 
symptom.  The  pulse  beats  from  100  to  120  per  minute  usually, 
but  may  rise  to  160  or  even  200.  Its  rhythm  is  usually  steady; 
but  palpitations  occur  easily,  even  without  exciting  cause.  The 
patient  may  wake  up  at  night  with  distressing  attacks,  something 
like  those  of  angina  pectoris,  but  the  intense  pain  and  sense  of  im- 
pending death  are  usually  absent.  The  heart  is  dilated  and  a  sys- 
tolic murmur  is  often  heard  at  the  base  propagated  along  the  ar- 
teries. Real  organic  disease,  however,  is  rare.  The  arteries  are 
dilated  and  soft.  They  pulsate  strongly,  particularly  the  carotids. 
A  thrill  is  sometimes  felt  over  the  heart  and  always  over  the  goitre. 
The  arterial  tension  is  normal  or  low. 

The  thyroid  gland  is  usually  enlarged  symmetrically ;  later  in 
the  disease  the  isthmus  is  affected  and  the  three  lobes  of  the  gland 
stand  out  prominently  (Fig.  227).  If  only  part  of  the  gland  is  in- 
volved it  is  oftenest  the  right  lobe.  A  thrill  is  felt  over  it  and  a 
systolic  murmur  can  be  heard. 

The  bulging  of  the  eyes  or  exophthalmus  is  usually  bilateral  and 
even.  If  one  eye  is  alone  or  more  affected  it  is  the  right.  The  ex- 
ophthalmus varies  much  in  degree.  It  is  not  usually  very  great,  but 
may  be  so  excessive  as  to  prevent  closing  of  the  lids  and  to  expose 
the  insertions  of  the  recti.  The  eyeball  may  be  slightly  enlarged 
(one-tenth).  The  pupils  are  normal  and  vision  is  not  impaired, 
though  myopia  occasionally  occurs.  The  fundus  and  visual  field 
are  normal.  Paralysis  of  some  of  the  eye  muscles  is  a  rare  com- 
plication. Weakness  of  the  internal  recti  and  exophoria  are  fre- 
quent. The  lids  show  certain  peculiarities.  One  of  these,  known 
as  Von  Graefe's  symptom,  consists  in  the  inability  of  the  lid  to 
follow  the  downward  movement  of  the  eyeball.  When  the  patient 
is  told  to  follow  the  movement  of  the  finger  vertically  downward 


EXOPHTHALMIC    GOITRE. 


547 


the  eyeball  moves  steadily,  but  the  lid  catches,  as  it  were,  and  re- 
fuses to  follow  or  does  so  in  a  jerky  manner.  Another  symptom, 
known  as  Stellwag's  symptom,  is  a  considerable  retraction  of  the 
lids,  especially  the  upper  one.  Both  this  and  Von  Graefe's  symp- 
tom are  due  to  a  common  tendency  of  the  lids  to  retract — due  per- 
haps to  overaction  of  the  muscle  of  Miiller.  A  tremor  of  the  lids 
sometimes  occurs. 

Course. — The  disease  progresses  slowly.  After  a  year  or  two 
it  often  becomes  stationary  for  a  long  time.  Cases  of  gradual  spon- 
taneous recovery  occur.  The  natural  duration  of  most  recoverable 
cases  is  two  or  four  years.     In  those  which  do  not  recover  the  dis- 


Fig.  227.— Exophthalmic  Goitre  ■with  and  •without  Exophthalmus. 


ease  lasts  five,  ten,  or  more  years.  Eventually  the  patient  emaci- 
ates, the  heart  becomes  weaker,  albuminuria  and  dropsy  appear, 
diarrhoea  sets  in,  and  the  patient  dies  of  exhaustion  or  is  carried  off 
by  phthisis  or  some  intercurrent  disease.  Other  cases,  having  im- 
proved up  to  a  certain  point,  remain  in  this  state  for  years. 

Complications* — Mental  derangement  occasionally  occurs  in  the 
later  stages  of  the  disease.  Hysterical  crises,  epileptic  attacks, 
choreic  movements,  paralysis  of  the  ocular  muscles,  muscular 
atrophy,  paralysis  agitans,  Addison's  disease,  diabetes,  locomotor 
ataxia,  and  local  oedema  have  all  been  observed.  With  the  excep- 
tion of  hysterical  attacks  these  complications  arc  rare 

Abort  ire  Forms. — This  name  is  applied  to  cases  in  which  only  a 
part  of  the  distinctive  symptoms  develop.  Tachycardia  always 
exists;  with  it  are  tremor  and  moist  skin,  lessened  electrical  resist- 


548  DISEASES   OF   THE   NERVOUS   SYSTEM. 

anee  and  nervousness.     Or  tachycardia  and  goitre  may  alone  be 
present. 

I'utJiologlrol  Anatomy. — Post-mortem  examination  of  this  gland 
shows  that  it  undergoes  a  true  hypertrophy  with  increase  of 
vascularity  and  of  the  glandular  structure.  The  rational  infer- 
ence is  that  in  life  there  is  an  increase  in  the  secretions  from 
this  structure.  After  the  hypertrophy  has  reached  a  certain  stage, 
the  glandular  epithelium  degenerates  and  breaks  down,  forming 
large  acini  filled  with  the  colloid  secretion.  In  the  nerve  centres 
the  changes  which  have  been  found  are  small  hemorrhages  in  the 
medulla  and  degenerated  nerve  cells.  In  one  case  of  about  a  year's 
standing,  I  found  a  very  marked  pigmentation  and  vacuolization  of 
the  cells  of  the  vagus  and  glosso-pharyngeal  nuclei.  In  another 
case  of  six  months'  standing,  no  marked. changes  could  be  seen  in 
these  areas,  bat  there  was  a  spot  of  softening  at  the  junction  of  the 
pons  and  the  cerebral  peduncle.  This  was  ante  mortem  and  had  led 
to  crossed  paralysis  just  a  few  days  before  death.  In  other  cases 
congestion  and  small  hemorrhages  in  the  medulla  have  been  found. 
The  heart  is  dilated  and  enlarged;  endocarditis  is  sometimes  present, 
oftener  not;  the  arteries  are  dilated. 

Patliohxjtj. — Some  writers  now  consider  this  disease  primarily 
one  due  to  a  disordered  function  of  the  thyroid  gland.  From  my 
own  observation  I  am  led  to  the  conclusion  that  Basedow's  dis- 
ease is  primarily  one  of  nervous  origin,  but  that  the  thyroid  dis- 
ease leads  to  excessive  secretion,  causing  the  principal  symptoms. 
The  nervous  tissues  require  for  their  proper  nourishment  and 
natural  functioning  a  certain  supply  of  the  secretion  of  the  thy- 
roid gland.  If  this  is  excessive,  there  is  a  state  of  nervousness 
and  erethism,  such  as  we  see  in  Basedow's  disease,  and  if  it  is  di- 
minished there  develops  a  hebetude  and  depression  of  nerve  func- 
tion, such  as  we  find  in  myxcedema.  Under  the  influence  of  shock 
and  powerful  emotion  or  prolonged  strain,  there  is  a  certain  power- 
ful demand  upon  the  product  of  the  thyroid  gland  by  the  nerve 
centres.  The  thyroid  juice  is  thrown  out  m  great  amount,  and  in 
persons  of  unstable  organism  a  morbid  impetus  is  given  to  the  activ- 
ity of  the  gland.  It  continues  to  grow  and  throw  out  its  juice ;  the 
overexerted  nervous  system  makes  continually  more  demand  upon 
it,  thus  acting  in  a  vicious  circle.  So,  while  the  symptoms  of  the  dis- 
ease, the  nervousness,  the  insomnia,  and  the  vasomotor  disturbances 
are  due  to  the  hypersecretion  of  thyroid,  the  primary  disturbance 
is  one  in  the  nerve  centres.  If  these  can  be  kept  quiet  long  enough, 
the  demand  on  their  part  for  this  excess  of  thyroid  juice  gradually 
ceases  and  the  patient  gets  well.     This  is  the  rationale  of  the  pro- 


EXOPHTHALMIC    GOITRE.  540 

longed  rest  and  the  use  of  the  bromides  and  tonics,  which  are  the 
only  things  which  do  much  good  in  the  treatment  of  the  disease. 

As  to  the  special  cause  of  the  different  symptoms,  it  may  be  as- 
siimed  that  the  original  enlargement  of  the  thyroid  is  a  vasomotor  par- 
esis of  its  vessels.  It  is  a  kind  of  erection  of  the  organ,  due  to  the 
sudden  demand  put  upon  it  by  emotional  strain  and  exhausting  work. 
The  exophthalmus  is  also  due  chiefly  to  paralysis  of  the  orbital  ves- 
sels. A  tonic  spasm  of  the  muscle  of  Muller  is  thought  to  help  in 
producing  this  symptom.  This  muscle  consists  of  unstriated  fibres 
originating  in  the  membranous  lining  of  the  orbit  and  inserted  into 
the  lids.  It  is  rudimentary  in  man,  and  its  influence  in  causing 
protrusion  of  the  globe  must  be  \erj  small.  The  deposit  of  retro- 
bulbar fat  is  a  secondary  phenomena.  The  rapid  heart  beat  is 
probably  due  to  impairment  of  the  inhibitory  fibres  of  the  spinal 
accessory. 

Prognosis. — About  one-fifth  of  the  cases  get  well  or  practically 
well.  Probably  over  half  the  cases,  if  they  can  be  properly  treated, 
reach  a  fairly  comfortable  condition  of  improvement.  The  cases  in 
which  symptoms  come  on  quickly  have  the  most  favorable  progno- 
sis. In  those  with  marked  exophthalmus  and  goitre  the  prognosis 
is  not  so  good.  The  duration  of  the  disease  in  recovering  cases  is 
from  two  to  eight  years. 

Diagnosis. — The  disease  can  be  distinguished  by  the  persistent 
tachycardia,  with  goitre  or  exophthalmus,  and  in  its  early  stage  by 
the  tachycardia  with  tremor,  moist  skin,  sensations  of  heat,  ner- 
vousness, insomnia,  lessened  respiratory  expansion,  and  electrical  re- 
sistance. A  symptomatic  Graves'  disease  may  sometimes  be  caused 
by  a  goitre  pressing  on  the  vagus  or  sympathetic  and  causing  irreg- 
ular heart  beat  and  perhaps  exophthalmus.  In  these  cases  the  his- 
tory of  a  long-standing  goitre  exists,  the  heart's  action  is  irregular, 
the  exophthalmus  is  usually  partial  and  one-sided.  In  abortive 
forms  it  is  necessary  to  have  tachycardia  and  at  least  one  other  of 
the  four  major  symptoms  to  make  a  diagnosis. 

Treatment. — Rest  is  the  most  important  single  thing.  The  pa- 
tient should  be  put  to  bed  or  kept  on  the  back  for  one  or  more 
months.  Freedom  from  excitement  and  worry  must  be  enjoined. 
No  especial  diet  is  needed,  nor  do  climatic  influences  or  baths  or 
mineral  waters  have  much  effect.  Some  cases  are  said  to  be  im- 
proved, however,  by  removal  to  heights  of  one  to  three  thousand 
feet.  In  most  cases  a  sea  voyage  is  the  better  change  if  one  is 
made. 

The  drugs  used  are  numerous.  The  most  efficient  are  tincture 
of  strophanthus  in  doses  of  fifteen  to  forty  drops  daily  j  iodide  of 


550  DISEASES   OF   THE   NERVOUS   SYSTEM. 

potassium  or  the  syrup  of  hydriodic  acid;  arsenic  and  bromide  of 
potassium  used  together;  quinine,  mineral  acids,  and  iron,  used  to- 
gether. Dilute  phosphoric  acid  is  often  very  useful.  Other  rem- 
edies are  tincture  of  aconite  in  v\  v.  or  aconitia  in  gr.  ^^  doses,  tinc- 
ture of  belladonna  increased  to  the  limit  of  tolerance,  tincture  of 
cactus  grandiflorus  in  1T[  x.  to  xx.  and  tincture  of  veratrum  viride, 
Til  x-  t°  xxx-  dose,  and  the  picrate  of  ammonium,  gr.  i.  to  ij.  t.i.d. 
Of  these  drugs,  strophanthus,  aconite,  the  iodides,  bromides,  and 
iron  have  served  me  best.     Digitalis  is  of  doubtful  value.* 

Electricity  possesses  some  utility.  It  should  be  given,  if  pos- 
sible, two  or  three  times  daily  in  the  form  of  galvanism  and  in  doses 
of  two  to  six  milliamperes  for  ten  minutes.  The  technique  is  as 
follows :  positive  pole  on  back  of  neck,  negative  drawn  along  course 
of  vagi  in  the  neck;  each  side  two  minutes.  Same  with  positive 
pole  placed  subaurally  one  minute ;  negative  pole  over  thyroid  two 
minutes,  negative  over  cardiac  region  one  minute,  positive  pole  over 
eyes,  negative  over  thyroid  one  minute,  two  milliamperes.  The 
faradic  current  may  be  used  for  general  tonic  effects  or  combined 
locally  with  the  galvanic.  The  patient  should  lie  down  during 
treatment  and  remain  quiet  for  an  hour  later. 

For  the  palpitations,  sulphate  of  sparteine  or  strophanthus  with 
Hoffmann's  anodyne  may  be  used.  The  ice  bag  placed  over  the 
heart  and  neck  is  helpful  and  may  be  used  systematically.  Tonic 
hydrotherapy  is  often  useful,  but  should  be  carefully  employed. 
Surgical  treatment  until  late  years  has  been  unsuccessful.  Recently 
many  cases  have  been  reported  in  which  cure  has  been  produced 
by  partial  removal  of  the  thyroid  gland.  This  measure  is  yet  in 
an  experimental  stage.  Treatment  of  the  nose  has  been  said  to 
cause  disappearance  of  symptoms,  but  its  utility  is  very  doubtful. 
Respiratory  exercises  by  which  the  patient  is  taught  to  increase  his 
chest  expansion  do  some  good.  Mild  compression  of  the  lids  at 
night  seems  to  help  the  exophthalmus,  and  slight  and  steady  com- 
pression of  the  thyroid  gland  sometimes  reduces  its  size  a  little. 

*  Some  writers  now  lay  great  stress  on  the  direct  treatment  of  the  thyroid 
gland  by  rubbing  upon  it  daily  the  ointment  of  the  red  iodide  of  mercury ; 
or  by  painting  it  with  iodine. 


CHAPTER  XXVI. 

PROFESSIONAL  NEUROSES,   OCCUPATION  NEUROSES 
(WRITERS'   CRAMP  AND  ALLIED  AFFECTIONS). 

Writers'  cramp  is  a  chronic  functional  neurosis  characterized 
by  spasmodic,  tremulous,  inco-ordinate  or  paralytic  disturbance 
when  the  act  of  writing  is  attempted,  and  associated  with  feelings 
of  fatigue  and  pain. 

Etiology.  —  It  is  a  disease  of  the  present  century,  and  has  been  par- 
ticularly noted  since  the  introduction  of  steel  pens  about  the  year 
1820.  A  neuropathic  constitution  is  often  present,  and  sometimes 
there  is  a  hereditary  history.  Men  are  much  more  subject  to  the 
disease  than  women.  The  most  susceptible  age  is  between  twenty- 
five  and  forty.  It  rarely  occurs  after  fifty  or  before  twenty.  Clerks 
and  professional  writers  are  naturally  much  more  subject  to  the  dis- 
ease. Excessive  worry,  intemperance,  and  all  debilitating  influences 
predispose  to  it.  The  chief  exciting  cause  is  excessive  writing. 
But  this  is  not  all.  The  writing  that  is  done  under  strain  or  a  de- 
sire to  finish  a  set  task  is  the  harmful  thing.  The  style  of  writing 
is  also  an  important  factor.  Writing  done  in  a  cramped  posture 
with  movements  of  the  finger  alone  or  with  the  little  finger  or  wrist 
resting  on  the  table  is  most  injurious.  Free-hand  writing  done 
from  the  shoulder  according  to  the  American  system  is  least  harm- 
ful. Shaded  or  heavy  writing  with  sharp  steel  pens  is  also  pro- 
ductive of  harm.  Copying  is  much  more  harmful  than  composing. 
Authors  seldom  have  writers'  cramp.  Albuminuria,  lead  poison- 
ing, exposure  to  wet  and  cold,  and  local  injuries  are  sometimes 
exciting  causes. 

Symptoms. — Writers'  cramp  very  rarely  attacks  a  person  sud- 
denly. The  patient  first  notices  a  certain  amount  of  stiffness  occur- 
ring at  times  in  the  fingers,  or  the  pen  is  carried  with  some  uncer- 
tainty and  jerky  movements  are  made.  He  feels  a  sensation  of 
fatigue  in  the  hand  and  arm,  and  this  may  amount  to  an  actual 
tired  pain.     The  first  symptoms  may  last  for  months  or  even  years. 


552  DISEASES    OF   THE    NERVOUS   SYSTEM. 

The  hand  is  rested  as  much  as  possible ;  new  pens  or  penholders 
and  new  modes  of  holding  it  are  tried.  Often  the  patient,  fearing 
the  onset  of  the  cramp,  and  as  its  result  loss  of  employment,  be- 
comes anxious,  worried,  and  mentally  depressed.  Sometimes  the 
trouble  is  worse  when  beginning  a  daily  task,  and  it  gradually  wears 
off  in  a  few  hours.  At  other  times  exactly  the  reverse  is  the  case. 
When  the  disease  has  reached  its  highest  stage,  writing  becomes  al- 
most or  entirely  impossible.  The  moment  the  pen  is  taken  in  the 
hand  and  an  attempt  at  using  it  made,  spasmodic  contractions  of 
some  of  the  fingers,  or  even  of  the  arm,  occur,  the  pen  flies  in  any 
direction,  and  it  is  impossible  to  control  or  co-ordinate  the  move- 
ments. The  rule  is  that  although  writing  cannot  be  done,  all  other 
complex  movements  are  performed  as  well  as  ever.  Thus  the  suf- 
ferer from  writers'  cramp  may  be  able  to  play  the  piano,  or  paint, 
or  thread  a  needle,  or  use  the  hand  in  any  complex  movements. 
This  limitation,  however,  is  not  always  present.  Telegraphers, 
who  use  to  some  extent  the  same  muscles  as  in  writing,  and  who 
also  often  have  to  do  a  great  deal  of  writing,  are  liable  to  suffer 
from  both  writers'  and  telegraphers'  cramp  at  the  same  time.  No 
evidences  of  actual  paralysis  are  present  in  the  affected  muscles, 
and  there  is  rarely  anaesthesia,  but  the  arm  aches  and  is  sometimes 
tender.  Sensations  of  numbness  and  prickling  are  present:  in  rare 
cases  vasomotor  disturbances  are  observed;  associated  muscular 
movements  of  the  other  arm  or  of  the  neck  or  face  sometimes  occur. 
The  hand  may  tremble  on  attempting  to  write  or  fall  almost  para- 
lyzed when  the  pen  is  taken. 

The  various  symptoms  occur  with  different  degrees  of  promi- 
nence, so  that  the  disease  has  been  classed  under  the  heads  of  (1) 
the  spastic,  (2)  the  neuralgic  or  sensory,  (3)  the  tremulous,  and  (4) 
the  paralytic  forms.  These  forms  are,  however,  often  more  or  less 
mixed. 

1.  The  spastic  form  is  undoubtedly  the  most  common,  and  it 
has  given  to  the  disease  its  name.  Cramp  of  some  muscle  or  mus- 
cles is  present  in  over  half  of  the  cases.  The  muscles  of  the  thumb 
and  first  three  fingers  are  oftenest  affected,  and  in  some  cases  the 
flexors,  in  some  the  extensors,  are  chiefly  involved.  In  telegraph- 
ers' cramp  it  is  the  extensors,  but  in  writers'  cramp  the  flexors,  that 
are  mainly  attacked.  The  thumb  or  forefinger  or  the  little  finger 
alone  may  suffer  from  the  spasms.  The  pronators  and  supinators 
are  quite  often  involved.  The  spasm  is  usually  a  tonic  one.  With 
the  spasm  there  is  also  inco-ordination  so  far  as  writing  movements 
are  concerned,  and  this  fact  is  quite  as  important  in  producing  the 
bad  writing  as  the  spasm. 


PROFESSIONAL   LEUKOSES,  OCCUPATION    NEUROSES.  553 

2.  The  neuralgic  form  resembles  the  spastic  plus  sensations  of 
fatigue  and  pain,  which  are  quite  severe  and  are  brought  on  by 
writing.     There  may  be  tenderness  along  the  arm  also. 

3.  The  tremulous  type,  though  rare,  is  very  characteristic  when 
present.  The  patient  when  attempting  to  write  develops  a  tremu- 
lous movement  of  his  hand  and  arm.  This  ceases  when  his  attempts 
to  write  cease.  The  tremor  usually  affects  most  the  fingers  used  in 
pen  prehension,  but  it  also  spreads  to  the  forearm  and  may  even  in- 
volve the  entire  extremity.  An  oscillatory  or  lateral  tremor,  due  to 
involvement  of  the  pronators  and  supinators,  has  been  observed. 
The  tremor  is  of  the  character  known  as  "intention  tremor,"  such 
as  is  observed  in  disseminated  sclerosis.  It  is  shorter  in  range  and 
more  rapid  than  the  tremor  of  that  disease. 

4.  The  paralytic  form,  or  that  type  in  which  muscular  feeble- 
ness is  the  dominant  symptom,  is  said  to  be  rare  by  Gowers,  and 
this  accords  with  n:^  experience.  German  writers  speak  of  it  as 
common.  In  the  typical  paralytic  form  the  patient,  as  soon  as  he 
begins  to  write,  feels  an  overpowering  sense  of  weakness  and  fatigue 
in  the  fingers  and  arm.  The  fingers  themselves  loosen  their  grip 
and  the  pen  may  drop  from  the  hand.  Powerful  impulses  of  the 
will  and  change  in  the  mode  of  holding  the  pen  enable  the  sufferer 
to  continue,  but  the  arm  aches  and  finally  is  absolutely  painful,  and 
weakness  and  fatigue  compel  the  writer  to  desist.  Sometimes  the 
paretic  condition  is  succeeded  by  the  spastic.  Many  of  the  cases  of 
paralytic  writers'  cramp  are  not  true  examples  of  the  neurosis,  but 
are  rather  cases  of  neuritis  of  a  rheumatic  or  other  type. 

General  Symptoms. — Writers'  cramp  is  essentially  a  motor  neu- 
rosis, and  its  leading  symptom  is  the  impairment  of  a  motor  func- 
tion. Other  symptoms,  however,  both  general  and  local,  are  al- 
ways associated  with  it.  These  are  mainly  (1)  psychical  and  (2) 
sensory,  more  rarely  (3)  vasomotor  and  (4)  trophic. 

1.  Psychical  symptoms.  The  patient  is  often  nervous,  emo- 
tional, and  mentally  depressed  at  times.  He  suffers  from  insom- 
nia and  vertigo.  Patients  are  generally  unwilling  to  admit  that 
there  is  any  other  trouble  than  the  local  one,  and  only  careful  ex- 
amination may  bring  evidence  of  constitutional  trouble.  There  are 
cases  of  purely  mental  writers'  cramp. 

2.  Sensory  troubles.  These  consist  of  pains,  sense  of  fatigue, 
feelings  of  numbness,  prickling,  pressure,  weight,  tension,  constric- 
tion, etc.  Hyperesthesia,  and  more  rarely  anaesthesia,  are  also  ob- 
served. The  most  common  sensory  symptom  is  that  of  aching  and 
fatigue,  and  this  is  usually  confined  to  the  arm,  and  oftenest  runs 
along  the  course  of  the  radial  and  median  nerves.     The  cervical  ver- 


551  DISEASES    OF   THE    NERVOUS    SYSTEM. 

tebrae  may  be  tender,  and  sometimes  patients  have  a  headache  in 
the  parietal  region  of  the  side  opposite  the  affected  arm. 

3.  Vasomotor,  trophic,  and  secretory  disturbances.  The  condi- 
tion known  as  dig  it  I  mortui  has  been  observed,  coming  on  paroxys- 
mally.  It  is  a  symptom  which  the  general  neurasthenic  state  helps 
to  produce.  When  the  nerves  are  involved  decided  vascular  changes 
may  occur,  such  as  passive  congestion  of  the  hand  and  arm,  with 
swelling  and  turgescence  of  the  fingers,  and  a  sensation  of  throb- 
bing. In  bad  cases  the  fingers  will  look  as  if  they  had  chilblains. 
Local  sweating,  dryness  of  the  skin,  and  cracking  of  the  nails,  all 
are  conditions  which  may  follow  impairment  of  writing  power  from 
neuritic  causes. 

Electrical  Reactions. — The  results  of  observations  upon  the  elec- 
trical reactions  of  the  affected  parts  are  somewhat  contradictory. 
Ordinary  tests  will,  as  a  rule,  reveal  very  little  change.  Sometimes 
there  is  a  quantitative  increase,  sometimes  a  decrease,  of  irritability 
to  both  forms  of  current.  The  increase  occurs  in  the  earlier  stages, 
the  decrease  in  the  later.  An  increase  or  modification  of  electro- 
muscular  sensibility  has  been  noted.  The  electrical  examinations, 
therefore,  are  only  of  value  in  excluding  a  neuritis  or  possibly  in 
determining  the  stage  of  the  disease. 

Pathology. — Neuritis  is  undoubtedly  present  in  some  forms  of 
writers'  cramp,  so  called.  It  is  not  present,  however,  so  far  as  ex- 
ternal tests  go,  in  the  typical  neurosis.  Nor  are  there  any  post-mor- 
tem observations  throwing  light  on  the  anatomy  of  the  disease.  We 
must  believe,  therefore,  that  it  is  a  neurosis  having  no  appreciable 
anatomical  basis. 

The  act  of  writing  is  a  very  complicated  one,  calling  into  play 
numerous  sets  of  delicately  innervated  muscles.  These  muscles  are 
employed:  1,  in  pen  prehension ;  2,  in  pen  movement;  3,  in  hold- 
ing the  arm  and  wrist  tense. 

1.  The  muscles  employed  in  pen  prehension  are  the  two  outer 
lumbricales,  two  outer  interossei,  the  adductor  muscles  of  the  thumb, 
the  flexor  longus  pollicis ;  to  some  extent  the  deep  and  superficial, 
short  and  long  flexors,  and  the  extensors  of  the  thumb.  These  are 
supplied  mostly  by  the  ulnar  (interossei,  adductor  pollicis,  inner 
heads  of  deep  flexor  of  fingers,  and  inner  head  of  short  flexor  of 
thumb).     The  rest  of  the  muscles  are  supplied  by  the  median. 

2.  In  moving  the  pen,  if  the  writing  is  clone  mainly  by  finger 
and  not  by  arm  movements,  the  muscles  brought  into  play  are  the 
flexor  longus  pollicis,  extensor  secundi  internodii  pollicis,  flexor  pro- 
fundus digitorum,  extensor  communis  digitorum,  and  to  some  ex- 
tent the  interossei.     The  musculo-spiral  and  ulnar  nerves  innervate 


PROFESSIONAL   NEUROSES,  OCCUPATION    NEUROSES.  555 

these  groups  about  equally.  In  moving  the  pen  by  the  "  American" 
or  free-hand  method  there  is  a  very  slight  play  of  the  above  mus- 
cles, while  most  of  the  pen  movement  is  done  by  the  muscles  of  the 
upper  arm  and  shoulder,  viz.,  the  teres  major,  pectorales,  latissimus 
dorsi,  biceps,  and  triceps. 

The  spinal  centres  for  these  muscles  are  distributed  along  the 
fifth,  sixth,  and  seventh  cervical  segments  of  the  cord.  The  cells 
are  larger  and  situated  more  superficially  in  the  anterior  gray  horns. 

3.  Besides  these  movements  involved  in  pen  prehension  and  in 
the  letter  making,  a  certain  amount  of  muscular  tension  is  exercised 
in  "  poising"  the  forearm  and  hand  and  steadying  the  wrist.  The 
biceps  and  triceps,  the  supinators  and  the  flexors  and  extensors  of 
the  hand  are  here  brought  into  play. 

Prom  the  foregoing  it  will  be  seen  that  the  muscles  of  pen  pre- 
hension are  most  used  in  all  but  the  free-hand  style  of  writing, 
since  the  same  groups  have  a  double  duty,  that  of  clasping  and  of 
moving  the  instrument. 

While  writers'  cramp  is  often  complicated  with  some  neurotic 
disturbance  leading  to  symptoms  in  the  affected  arm  of  pain,  paral- 
ysis, tenderness  over  nerves,  vasomotor  disturbances,  etc.,  there  can 
be  no  doubt  that  the  lesion  in  typical  cases  is  central,  and  involves 
the  psycho-reflex  centres  and  indirect  motor  and  sensory  paths. 
Little  more  can  be  said  of  the  pathology  than  that  it  is  an  '"  ex- 
haustion neurosis."  The  same  is  true  of  all  the  other  forms  of  oc- 
cupation neuroses,  and  nothing  need  be  said  upon  this  point  regard- 
ing them  when  they  come  to  be  considered. 

The  diagnosis  of  well-marked  cases  of  writers'  cramp  presents 
no  difficulty.  In  the  earlier  stages,  however,  it  may  be  confounded 
with  a  large  number  of  disorders,  viz.,  post-hemiplegic  chorea,  he- 
miataxia,  progressive  muscular  atrophy,  progressive  locomotor  ataxia, 
various  forms  of  tremor,  lead  paral}*sis,  rheumatoid  arthritis,  neu- 
ritis, cerebral  and  nerve  tumors,  and  tenosynovitis. 

In  many  of  these  cases  it  is  only  necessary  to  bear  in  mind  the 
history  of  the  disease  in  order  at  once  to  reach  a  safe  conclusion  as 
to  its  nature. 

If  there  is  a  great  deal  of  pain  in  the  arm,  with  tenderness  along 
the  course  of  the  nerves;  if  there  is  decided  change  in  the  electrical 
reactions;  if  there  are  sensations  of  tingling,  numbness,  etc.;  and 
if  the  patient  shows  an  absolute  loss  of  power  in  the  various  groups 
of  muscles,  with  some  incapacity  for  doing  other  acts  besides  the 
one  with  which  he  is  specially  concerned,  then  the  trouble  is  un- 
doubtedly peripheral  and  due  largely  to  an  underlying  neuritis. 
The  prognosis  in  these  cases  is  much  more  favorable.     If,  on  the 


556  DISEASES   OF   THE   NERVOUS    SYSTEM. 

other  hand,  the  disorder  comes  on  in  persons  who  have  done  an  ex- 
cessive amount  of  writing;  if  it  is  associated  with  nerve  strain;  if 
the  electrical  reactions  are  but  slightly  changed,  the  sensory  symp- 
toms slight,  and  the  motor  inco-ordination  is  marked,  limited  to  the 
special  class  of  work,  and  not  accompanied  with  absolute  paresis, 
the  disorder  is  central  and  needs  both  a  different  treatment  and 
prognosis.  It  is  these  cases  that  form  writers'  cramp  proper,  al- 
though no  doubt  neuritic  and  central  forms  are  associated,  or  the 
former  may  run  into  the  latter. 

Course  and  Duration. — Writers'  cramp  is  a  chronic  disease.  It 
begins  insidiously  and  attacks  one  group  of  muscles  after  another  as 
each  is  brought  into  play  by  new  methods  of  writing.  If  the  left 
hand  is  used,  that,  too,  is  liable  to  become  affected.  The  course 
varies,  however;  for  a  time  progress  maybe  arrested  or  improve- 
ment set  in.  When  the  disease  becomes  well  established  it  will 
most  often  last  a  lifetime. 

Prognosis. — The  prognosis  is  unfavorable,  yet  not  so  much  so 
as  was  once  thought.  Undoubted  cases  of  pomplete  recovery  have 
been  reported,  even  under  unfavorable  conditions.  The  prognosis 
is  much  more  favorable  if  the  patient  begins  treatment  early  and 
before  marked  spastic  symptoms  are  present.  It  is  more  favorable 
in  the  neuralgic  forms.  Some  patients  who  suffer  from  a  mild 
form  of  the  trouble  manage,  by  the  help  of  instruments  or  special 
pens,  to  do  their  work  for  years.  The  more  acute  the  disease  and 
the  more  evidently  peripheral  and  neuritic  its  origin,  the  better  the 
prognosis.  In  over  one-fourth  of  the  cases,  patients  who  use  their 
sound  arm  will  not  be  affected  in  it. 

The  facts  stated  regarding  the  cause,  physiology,  and  general 
symptomatology  of  writers'  cramp  apply  to  the  other  forms  of  occu- 
pation neuroses.  A  few  special  details,  however,  will  be  given  re- 
garding these.  The  most  common  and  important  are  musicians' 
cramp  and  telegraphers'  cramp. 

Musicians'  Cramp. — Under  this  head  we  include  pianists' 
cramp,  violinists'  cramp,  flutists'  cramp,  and  the  cramp  of  clari- 
onet players. 

Pianists'  cramp  occurs  usually  in  young  women  who  are  study- 
ing to  become  professionals  or  who  are  especially  hard  working  and 
ambitious.  The  absurd  "  Stuttgart  method"  of  teaching  the  piano, 
in  which  the  motions  are  confined  as  much  as  possible  to  the  fin- 
gers, predisposes  especially  to  this  disease.  The  symptoms  are  those 
of  fatigue,  pain,  and  weakness.  The  pains  are  of  an  aching  char- 
acter. They  are  felt  in  the  forearm  especially,  but  extend  up  the 
arm  and  between  the  shoulders.  Spasmodic  symptoms  are  rare. 
The  right  hand  is  oftener  affected,  but  both  hands  eventually  be- 
come involved. 


PROFESSIONAL   NEUROSES,  OCCUPATION   NEUROSES.  557 

Violinists'  cramp  may  attack  the  right  hand  which  holds  the 
bow  or  the  left  hand  which  fingers  the  strings,  but  more  often  the 
left  hand  is  affected. 

Clarionet  players  sometimes  suffer  from  cramp  of  the  tongue  and 
of  the  laryngeal  muscles. 

Flute  players  suffer  not  very  infrequently  from  slight  laryngeal 
spasms.  A  similar  trouble  affects  elocutionists.  The  term  mogo- 
phonia  is  applied  to  this  type. 

Telegraphers'  cramp  affects  especially  those  operators  using  the 
Morse  system,  which  is  still  the  one  most  widely  in  vogue.  Con- 
trary to  the  opinions  of  previous  writers,  Dr.  Lewis  believes  that 
this  neurosis  is  not  a  rare  one  and  is  destined  to  become  more  fre- 
quent. In  this  city  the  cramp  is  not  rare,  the  proportion  being 
about  one  in  every  two  hundred.  The  technical  name  among 
operators  for  the  cramp  is  "  loss  of  the  grip. "  In  telegraphing,  the 
extensors  of  the  wrist  and  fingers  are  called  most  into  play,  and 
hence  are  most  and  earliest  affected.  The  symptoms  come  on  very 
slowly,  the  thumb  and  index  finger  being  first  affected.  The  victim 
finds  that  he  cannot  depress  the  key  on  account  of  spasm  in  these 
muscles,  and  he  finds  most  difficulty  in  making  the  dot  characters, 

such  as  h  (.   .   .   .),  or  p  ( ),  or  z  ( ).     When  the 

flexors  are  most  affected  the  key  is  depressed  with  undue  force  and 
a  dash  is  made  instead  of  a  dot.  Sufferers  from  the  "  loss  of  grip  " 
generally  have  writers'  cramp  also.  While  spasm  is  usually  pres- 
ent, the  disease  may  show  itself  simply  in  pain,  paresis,  and  in- 
capacity to  co-ordinate  the  muscles. 

In  seicing-spasm,  which  affects  tailors,  seamstresses,  and  shoe- 
makers, clonic  and  tonic  spasms  attack  the  muscles  of  the  hands 
on  attempting  to  use  them  in  the  regular  work.  Tailors  who 
sit  cross-legged  sometimes  suffer  from  a  peculiar  spasm  on  as- 
suming this  position.  It  is  possible,  however,  that  these  are 
cases  of  tetany,  and  not  the  functional  neurosis  under  considera- 
tion. 

Smiths?  spasm,  or  "heph&stie  hemiplegia"  appears  to  have  been 
observed  only  by  Duchenneand  Dr.  Frank  Smith.  It  occurs  in  per- 
sons engaged  in  pen-blade  manufacturing,  saw  straightening,  razor- 
blade  striking,  scissors  making,  file  forging,  etc.  In  doing  this  work 
they  have  to  use  a  light  or  heavy  hammer,  with  which  strokes  are 
delivered  very  rapidly  and  carefully.  After  a  time  spasmodic  move- 
ments occur  in  the  arm  used,  and  the  arm  falls  powerless.  As  in 
the  cases  reported,  there  are  generally  hemiplegic  symptoms,  and 
also  neuralgias,  vertigo,  and  other  cerebral  troubles,  the  disease 
cannot  be  a  pure  "  occupation"  neurosis. 

Drivers*  s/>asm  has  been  observed  in  veterinary  surgeons  by  Dr. 
Samuel  Wilkes. 

M&fcers?  spasm  is  an  extremely  rare  affection,  which  was  first 
described  by  Basedow  and  seems  to  occur  in  milkmaids,  never  in 
milkmen. 

Cigarmakerst  cramp  is  very  rare 


558  DISEASES   OF   THE    NERVOUS   SYSTEM. 

Watchmakers'  cramp  and  photographers1  cramp  are  also  to  be 
regarded  merely  as  pathological  curiosities. 

Ballet- Dancers'  Cramp).  — Under  this  name  certain  painful  and 
paralytic  troubles  occurring  in  ballet  dancers,  especially  premieres 
danseuses,  have  been  described  by  Schultz,  Onimus,  and  Kraus- 
sold.  It  does  not  appear  that  the  trouble  is  really  a  co-ordinative 
functional  one,  but  is  rather  neuralgic  or  the  result  of  local  strain 
upon  the  parts. 

The  list  of  professional  neuroses  is  made  to  include,  besides 
those  above  given,  cramps  and  co-ordinative  troubles  affecting  arti- 
ficial-flower makers,  billiard  players,  dentists,  hide  dressers,  elec- 
trical-instrument makers,  stampers,  turners,  sewing-machine  girls, 
money  counters,  weavers,  painters,  and  pedestrians. 

Prophylaxis  and  Treatment. — The  introduction  of  typewriters, 
gold  pens,  and  improved  penholders  has  prevented  somewhat  the 
increase  of  writers'  cramp.  Stenographers  rarely  have  it  unless 
they  write  in  long  hand.  Persons  who  have  to  write  a  great  deal 
should  use  large  cork  or  rubber  penholders  and  gold  or  quill  pens 
with  smooth  paper.  The  best  style  of  writing  is  that  done  from 
the  shoulder,  but  this  is  a  method  that  bookkeepers  and  those  who 
have  to  keep  accounts  cannot  easily  adopt.  The  vertical  system  of 
writing  which  is  now  being  widely  taught  is  to  be  preferred.  Many 
nervous  persons  have  a  bad  habit  of  gripping  the  pen  very  tightly  and 
pressing  down  on  the  paper  with  excessive  force.  Fatigue  soon  re- 
sults and  painful  sensations  develop  in  the  arm.  Proper  attention 
should  be  paid  to  the  position  of  the  paper  written  upon,  the  height 
of  the  desk,  the  light,  and  the  sleeves  of  the  coat  or  dress.  The 
paper  should  be  laid  at  an  oblique  angle  to  the  edge  of  the  desk, 
and  not  at  a  right  angle  as  many  writing-teachers  are  accustomed 
to  direct.  As  some  cases  of  "  cramp"  are  undoubtedly  cerebral, 
it  is  very  unwise  to  attempt  any  extraordinary  exploits  in  writing 
or  to  work  with  the  ambition  to  put  the  writing-capacity  to  the 
utmost  test.  Cramp  is  often  dated  from  days  when  such  extra  work 
is  done. 

When  the  cramp  is  fully  developed,  the  most  essential  thing  is 
rest,  and  it  is  generally  best  to  advise  the  patient  to  change  his  oc- 
cupation at  once.  Some  rest,  however,  may  be  secured  by  getting  a 
new  form  of  penholder,  holding  the  pen  in  a  different  way,  using  the 
unaffected  arm,  or  using  some  form  of  mechanical  appliance.  The 
mechanical  appliances  are  splints,  rubber  bands  around  the  wrist, 
and  various  instruments  contrived  to  prevent  spasm  and  throw  the 
work  of  writing  on  new  and  larger  groups  of  muscles. 

Instruments  for  writers'  cramp  are  very  numerous.  Those  that 
are  of  some  value  are  Mathieu's,  Nussbaum's,  and  some  modifica- 


PROFESSIONAL    NEUROSES,   OCCUPATION    NEUROSES. 


559 


tion  of  Cazenave's  (see  Figs.  228,  229).  All  the  various  instruments 
have  been  of  service,  or  have  even  been  curative  in  some  special 
cases,  but  not  too  much  must  be  expected  of  them.  As  a  rule  they 
are  only  palliative.  A  cheap  instrument  that  may  prove  satisfactory 
is  that  of  Mathieu. 

In  the  medical  treatment  of  writers'  cramp,  two  important  agents 
are  massage  and  electricity. 

By  massage  only  very  mediocre  results  were  obtained  until 
greater  attention  was  drawn  to  it  by  Mr.  J.  Wolff,  a  writing-mas- 
ter of  Frankfort-on-the-Main.  This  gentleman  has  cured  many 
cases,  though  not  all  that  he  has  treated  (Berger),  and  he  has 
secured  many  testimonials  for  his  method.  The  treatment,  as  de- 
scribed by  Schott  (G.  TV.  Jacoby),  consists  of  a  system  of  gym- 
nastics and  massage.     The  gymnastics  consist  of  movements  per- 


Fio.  328.—  Mathieu's  Instrument 
for  Writers'  Cramp. 


Fig.  229.— Nussbaum's  Instrument. 


formed  by  the  patient  alone  and  movements  executed  with  the 
co-operation  of  the  operator.  The  first  are  performed  by  the  pa- 
tient during  from  twenty  to  thirty  minutes,  rarely  for  forty-five 
minutes.  These  movements  consist  of  gymnastics  of  the  fingers; 
extension,  flexion,  abduction,  and  adduction  being  performed,  and 
the  thumb  being  exercised  separately.  After  this  the  four  motions 
are  executed  at  the  wrist-joint,  then  extension  and  flexion  of  the 
forearm,  and  ultimately  the  arms  themselves  are  exercised  in  the 
same  manner  and  are  to  be  lifted  over  the  head.  Each  single  ex- 
ercise is  to  be  performed  from  six  to  twelve  times.  After  each  mo- 
tion a  pause  is  to  be  observed.  The  opposed  movements  are  to  he 
rallied  out  in  the  same  manner,  except  that  the  operator  must  care- 
fully resist  their  execution  as  though  he  were  endeavoring  to  force 
the  patient  to  perform  a  motion  just  the  reverse  of  his  intentions. 
Regularity  of  pressure  is  to  he  observed  in  this,  so  that  the  same 
amount  of  force  is  always  used  and  so  that  the  pressure  does  not 


500  DISEASES   OE   THE  NERVOUS   SYSTEM. 

vary  in  intensity  from  moment  to  moment.  The  time  to  be  devoted 
to  these  opposed  movements  should  be  the  same  as  that  for  the  un- 
opposed ones.  According  to  the  intensity  of  the  affection,  the  exer- 
cises must  be  repeated  two  or  three  times  daily.  The  massage  it- 
self consists  of  two  parts — nerve  and  muscle  massage.  The  nerve 
massage  is  effleurage  along  the  course  of  the  nerve  trunks,  the  me- 
dian, ulnar,  and  radial,  going  upward  to  the  axillary  and  cervical 
plexuses.  This  effleurage  lasts  about  ten  minutes.  Following  this 
is  the  muscle  massage.  This  consists  of  petrissage,  beginning  with 
the  hand  and  ending  at  the  shoulder.  The  duration  is  the  same  as 
that  of  the  last  movement.  One  sitting  a  day  has  always  proved 
sufficient.  Wolff,  in  addition,  uses  "a  peculiar  method  of  writing 
instruction"  and  employs  rubber  bands  and  rings  in  his  manipula- 
tions. It  must  be  added  that  one  hears  very  little  of  the  "Wolff 
method  at  the  present  time. 

Electricity  ranks  second  to  massage  in  the  treatment  of  occupa- 
tion neuroses.  The  high-tension  faradic  current  with  long  coil  has 
done  good  service  in  some  of  my  cases.  The  galvanic  current  has 
been  helpful  also.  It  should  be  given  daily.  The  anode  is  placed 
over  the  cervical  spine  and  the  cathode  over  the  various  muscular 
groups  affected.  A  stabile  current  of  five  to  ten  milliamperes  for 
from  ten  to  fifteen  minutes  is  given. 

Lotions  containing  muriate  of  ammonium,  liniments,  hot  and  cold 
douches,  the  cautery,  all  have  been  recommended  in  professional 
neuroses.  Tenotomy  was  once  employed,  but  has  been  abandoned. 
Very  little  can  be  expected  of  drugs.  The  most  trustworthy  are 
atropine,  strychnine,  cannabis  indica,  the  iodides  and  bromides,  and 
cod-liver  oil.  It  should  be  remembered  that  sometimes  the  disease 
is  almost  purely  cerebral,  and  then  an  antineurasthenic  treatment 
is  called  for.  But  in  other  cases,  when  the  disorder  is  largely  pe- 
ripheral, the  usual  treatment  for  a  low  grade  of  myoneuritis  must 
be  employed. 


CHAPTER   XXVII. 

PARALYSIS  AGITANS  (SHAKING  PALSY,  PARKINSON'S 

DISEASE). 

Paralysis  agitans  is  a  chronic  progressive  disease,  characterized 
by  tremor,  muscular  rigidity  and  weakness,  and  by  a  peculiar  atti- 
tude and  gait,  together  with  sensations  of  heat,  pain,  and  restless- 
ness. 

Etiology. — It  occurs  oftenest  between  the  ages  of  fifty  and  sixty, 
then  between  sixty  and  seventy  and  forty  and  fifty.  In  very  rare 
instances  it  occurs  in  early  life,  but  the  genuine  disease  does  not 
occur  before  puberty.  ]\Iales  are  affected  much  oftener  than  females 
(five  to  three  in  seventy-eight  American  cases).  It  occurs  in  all 
classes  of  life,  but  oftener  among  those  who  incur  exposures  and  en- 
dure hard  labor.  It  is  not  a  disease  of  vice  and  is  not  the  result  of 
alcoholism,  syphilis,  or  sexual  excess.  Prolonged  overwork  and 
anxiety  in  middle  life  are  very  often  predisposing  causes.  Heredity 
is  a  rare  factor,  but  I  have  known  hereditary  family  tremor  to  end 
in  paralysis  agitans.  It  appears  to  have  some  relation  to  rheuma- 
tism and  especially  to  rheumatoid  arthritis.  It  occurs  oftenest  in 
this  city  among  the  Irish,  German,  and  Polish  races  (twenty  Irish, 
thirteen  Germans  and  Russians,  the  last  mostly  Hebrews). 

The  apparent  exciting  causes  in  the  majority  of  cases  are  ex- 
posure to  wet  and  cold,  fright,  injury,  and  acute  mental  suffering. 
An  attack  of  rheumatism,  a  sudden  severe  muscular  strain,  and 
fevers  are  rare  causes.  The  actual  exciting  cause  is  probably  al- 
ways an  infection,  just  as  in  multiple  sclerosis,  paralysis  agitans 
being  the  senescent  counterpart  of  that  disease. 

Symptoms. — The  disease  is  sometimes  ushered  in  with  an  acute 
illness,  or  an  attack  of  sciatica.  It  then  develops  slowly  with  some 
aching  pains  in  the  arm  and  a  slight  tremor  in  the  fingers  of  one  hand, 
oftener  the  left.  This  gradually  extends  and  involves  the  foot  of  the 
same  side,  then  the  other  side  becomes  affected.  The  neck,  face, 
and  tongue  are  rarely  attacked,  and  then  to  a  small  extent.  After 
or  with  the  tremor  there  comes  on  a  stiffness  in  the  arms  and  legs, 
and  indeed  of  the  whole  body.  With  this  there  is  a  general  con- 
tracturing  and  shortening  of  all  the  flexor  groups;  so  that  the  head 
and  body  are  bent  forward,  the  fingers  are  straight  but  are  flexed 


562 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


as  a  whole  on  the  metacarpus,  the  forearms  flexed  on  the  arm,  the 
trunk  is  flexed  forward  on  the  thighs,  and  the  knees  are  slightly  bent. 
The  attitude  gives  the  idea  of  extreme  senility  (Fig.  230).  The 
gait  is  slow,  the  steps  are  short  and  shuffling ;  the  patient  has  trouble 
in  starting,  stopping,  and  turning  corners,  owing  to  the  slowness 
in  initiating  new  movements  in  the  voluntary  muscles.     When  once 

started  he  may  be  unable  to  stop 
and  has  to  run  along.  The  speech 
early  becomes  affected.  The  voice 
is  high-pitched,  weak,  and  piping, 
or  senile  in  quality.  There  is  a 
slowness  in  getting  out  words  or  in 
starting  a  sentence,  though  after  it 
is  begun  the  words  come  rapidly. 
The  condition  is  analogous  to  the 
hestitation  in  the  gait. 

Along  with  the  other  symptoms 
there  are  often,  though  not  always, 
sensations  of  heat,  burning,  fever, 
and  rarely  of  coldness.  These 
sensations  are  felt  most  in  the 
feet,  legs,  or  arms  diffusely.  Often 
there  is  a  general  feeling  of  rest- 
lessness and  nervousness.  Aching 
pains  and  a  sense  of  fatigue  occur; 
neuralgic  pains  are  more  rare. 
There  are  always  a  peculiar  redness 
and  flush  in  the  faces  of  the  pa- 
tients. Sometimes  they  sweat  pro- 
fusely. The  temperature  in  the 
axilla  is  normal,  on  the  skin  it  is 
sometimes  increased  (Peterson). 
The  appetite  is  excellent,  often 
abnormally  great,  and  digestion 
is  good.  Visceral  complications  are  rare.  Muscular  weakness 
comes  on  early;  it  slowly  increases,  but  complete  muscular  paral- 
ysis does  not  occur.  The  disease  ends  in  rigidity,  which  makes  the 
patient  as  helpless  as  if  paralyzed,  but  the  muscles  preserve  consid- 
erable functional  power  to  the  last.  The  deep  reflexes  are  present 
and  not,  as  a  rule,  exaggerated ;  but  exaggeration  and  even  clonus 
occur  in  a  small  percentage  of  cases.  As  the  disease  progresses  the 
tremor  increases  in  extent,  and  continues  without  remission  during 
all  the  waking  hours;  the  limbs  get  more  rigid;  the  patient  becomes 


Fi^ 


230.— Attiti'de  in  Paralysis 
Agitass  (Curschmann). 


PAEALYSIS    AGITAXS. 


563 


bedridden  and  is  finally  carried  off  by  exhaustion  or  some  inter- 
current illness  (Fig.  231). 

It  will  be  seen  that  the  dominant  symptoms  in  paralysis  agitans 
are: 

1.  Tremor. 

2.  Rigidity,  progressively  increasing. 

3.  Muscular  weakness. 

4.  Sensory  and  vasomotor  disturbances. 

Further  details  must  be  given  regarding  these  symptoms : 
The  tremor  is  at  first  rather  fine,  but  later  is  coarse.     It  ranges 
from  about  6  vibrations  per  second  to  3.7.     The  average  rapidity  is 
4  or  5  per  second,  wliich  is  about  one-half  the  normal  muscular 


Fig.  231. — Attitude  and  Gait  in  Paralysis  Agitans. 

rhythm.  But  the  chief  characteristic  of  the  tremor  is  that  it  con- 
tinues when  the  hand  or  limb  is  at  rest,  while  voluntary  motion 
causes  it  to  cease.  As  the  hand  rests  on  the  knee  it  shakes ;  as  it  is 
moved  the  tremor  stops.  When  held  straight  out  there  is  no  shak- 
ing for  a  moment,  but  it  soon  begins.  A  glass  of  water  is  carried 
safely  to  the  lips.  The  patient  can  control  the  tremor  for  a  mo- 
ment, especially  in  the  early  stages  of  the  disease.  These  facts 
about  the  tremor  apply  in  ninety  per  cent  of  cases,  but  there  are 
patients  whose  tremor  is  slight  when  the  limb  is  at  rest  and  is  in- 
creased on  voluntary  effort.  The  hands  are  affected  in  a  character- 
istic way.  The  fingers  and  thumb  are  slightly  flexed  and  held  about 
in  the  writing-position ;  the  tremor  moves  the  fingers  and  thumb  as 
a  whole,  and  they  vibrate  so  that  the  one  pats  the  other  gently. 
Sometimes  the  tremor  is  one  of  alternate  supination  and  pronation 
of  the  forearm.     The  neck  and  face  muscles  are  not  usually  or  ex- 


564 


DISEASES   OF   THE    NEEVOUS    SYSTEM. 


tensively  involved,  the  shaking  of  the  head  being  generally  the  re- 
sult of  the  general  bodily  tremor.  Sometimes  one  sees  a  tremor  of 
the  lips  or  neck  muscles.  The  tongue  and  eye  muscles  are  practi- 
cally never  involved. 

Rigidity. — The   rigidity  comes   on  early,  and  may  be  the  first 
and  even  the  only    prominent  symptom.       It  affects  chiefly   the 


Fig.  233.— Terminal  Stage  op  Paralysis  Agitans,  showing  rigidity  and  contractures. 


flexors  of  the  arms,  head  and  trunk,  and  legs,  producing  a  char- 
acteristic senile  position.  In  rare  cases  the  extensors  of  the  neck 
are  affected  and  the  head  is  drawn  back.  Cramps  occur,  and  there 
is  always  a  sense  of  stiffness.  The  muscular  movements  are  slow, 
especially  the  initiation  of  a  movement.  Once  started,  a  motion 
may  be  quickly  done.  The  gait  is  peculiar :  the  steps  are  short  and 
shuffling;  the  patient  may  have  difficulty  in  starting,  but  once 
started  he  goes  along  very  well ;  or  while  walking  there  may  be  a  sud- 


PARALYSIS    AGITAXS.  565 

den  running  forward.  This  is  called  "  festination."  Rarely  there  is 
a  tendency  to  run  backward  or  sideways.  The  facial  muscles  are  stif- 
fened and  little  used,  so  that  the  face  has  a  peculiar  expressionless 
look.  The  patient  is  often  emotional,  but  the  mind  is  not  seriously 
affected.  The  urine  is  usually  about  normal,  but  contains  an  excess 
of  j)hosphates.     There  may  be  polyuria  and  less  often  glycosuria. 

Forms. — The  unusual  types  of  paralysis  agitans  are  the  hemi- 
plegic  or  the  monoplegic,  the  rigid  type,  and  the  retrocollic  type. 
The  only  one  of  importance  is  the  rigid  type,  in  which  there  is 
practically  no  tremor. 

Course  and  Duration. — The  disease  slowly  but  steadily  pro- 
gresses until  a  full  development  of  symptoms  occurs,  when  it  may 


Fici.  238.— Anterior  Horn  of  Spinal  Conn,  showing  dilated  veins. 

remain  stationary.  It  takes  about  two  years  for  the  whole  body  to 
be  affected,  though  this  varies  much.  It  lasts  from  three  to  twelve 
years  or  even  more.  In  three  cases  of  mine  death  occurred  in  three, 
six,  and  eleven  years.  Death  is  due  to  exhaustion  and  may  be  ac- 
companied  by  mild  delirium  and  fever. 

The.  diagnosis  must  be  made  from  senile  tremor,  multiple  scle- 
.  posthemiplegic  tremor,  and  wryneck  affecting  the  extensors 
bilaterally  (retrocollic  spasm).  Senile  tremor  occurs  in  the  very  old 
and  affects  the  head  first  and  most.  In  multiple  sclerosis  the  tremor 
is  more  jerky  and  is  a  tremor  of  motion;  there  are  nystagmus,  syl- 
labic speech,  and  often  apoplectiform  attacks,  eye  trouble,  and 
paralyses. 

Post-hemiplegie   tremor  is  accompanied  by  a  history  of  henii- 


566 


DISEASES    OF   THE    NEKVOUS    SYSTEM. 


plegia;  there  are  paralysis  and  exaggerated  reflexes  and  the  disease 
is  unilateral.     In  retrocollic  spasm  only  the  neck  muscles  and  fron- 


Sfc 


;/ 


7WJ 


i 


&, 


'i 


?■ 


%- 


Fig.  234.— Cells  op  the  Anterior  Horn  op  the  Spinal  Cord.  The  right  row  from 
a  case  of  paralysis  agitans,  showing  atrophy  and  pigmentation,  the  left  row  from  a 
normal  case. 

talis  are  involved.  The  absence  of  exaggerated  reflexes,  the  pecu- 
liar voice,  gait,  and  attitude,  and  the  sensations  of  heat  and  nervous- 
ness often  help  greatly  in  the  diagnosis. 


PARALYSIS    AGITANS.  567 

The  prognosis  is  favorable  as  regards  life ;  unfavorable  as  regards 
cure;  and  not  very  good  as  to  bringing  about  a  cessation  of  progress 
in  the  symptoms.  The  progress  of  the  malady,  however,  can  be 
delayed. 

Pathological  Anatomy  and  Pathology. — The  post-mortem  changes 
are  not  very  marked,  and  are  seen  mostly  in  the  spinal  cord  and 
medulla.  There  are  congestion  and  dilatation  of  vessels  in  the  gray 
matter,  a  diffuse  increase  of  interstitial  tissue,  atrophy  and  pig- 
mentation of  cells  (Figs.  233  and  234).  The  process  is  suggestive 
of  a  chronic  interstitial  inflammation  with  cell  degeneration.  It  is 
probably  a  post-infectious  process,  with  a  toxin  behind  it.  The 
cerebro-spinal  motor  neuron  is  the  most  at  fault;  and  it  seems  as 
if  the  connections  between  its  end  brushes  and  the  motor  cells  of 
the  spinal  cord  were  interfered  with.  Hence  the  peculiar  "  hold- 
ups; "  the  rigidity  and  tremor  of  the  disease. 

Paralysis  agitans  is  certainly  not  merely  a  premature  senility, 
as  some  have  taught. 

Treatment. — The  most  important  measure  is  rest,  mental  and 
physical,  with  plenty  of  fresh  air.  No  special  diet  is  indicated. 
Lukewarm  baths  and  mild  massage  are  agreeable  and  helpful.  I 
know  of  no  climatic  cure.  The  galvanic  current  produces  temporary 
relief;  it  should  be  given  daily.  Hyoscine  hydrobromate,  first  used 
by  Charcot  and  introduced  into  this  country  by  Seguin,  is  of  much 
temporary  value  in  relieving  the  tremor  (gr.  yi^  increased).  Codeine 
and  morphine  give  the  best  permanent  results.  Quinine  and  min- 
eral acids  are  of  much  service  in  relieving  the  vasomotor  and  sensory 
symptoms.  I  have  used  bromide  of  uranium  (gr.  -^)  with  some  ap- 
parently good  results.  Arsenic,  Indian  hemp,  tinct.  veratrum  viride, 
salicin,  and  salicy  ate  of  sodium  rank  next  in  value.  Nitrate  of  silver, 
conium,  curare,  bromides,  atropine,  phosphorus,  cod-liver  oil,  iron, 
and  picrotoxin  have  all  been  recommended.  Bromide  often  helps 
the  insomnia  and  restlessness.  Extract  of  pituitary  gland  in  doses 
of  gr.  xxx.  to  xl.  daily  quiets  the  system  also. 

Suspension  is  of  some  use  in  a  minority  of  cases  not  too  much 
advanced.  The  mind  in  paralysis  agitans  is  sometimes  in  an  emo- 
tional, almost  hysterical,  condition,  and  patients  are  easily  made 
better  for  a  time  by  some  psychical  influence.  Hypnotism  by  means 
of  fascination  is  said  to  be  of  use,  but  it  has  failed  in  my  experience. 


CHAPTER  XXVIII. 


TROPHIC   AXD  VASOMOTOR   DISORDERS. 

Progressive  facial  hemiatrophy  is  a  disease  characterized 
by  a  progressive  wasting  of  one  side  of  the  face. 

Etiology. — It  begins  oftenest  in  the  young  between  the  ages  of 
ten  and  twenty.  Females  are  more  affected.*  There  is  in  rare 
cases  a  hereditary  history.  Injury  and  infectious  fevers  sometimes 
start  up  the  trouble.     The  left  side  is  oftener  attacked. 

Symptoms. — The  disease  begins  very  gradually  and  shows  itself 


Pig.  23;").— Facial  Hemiatrophy.  Early  Stage,  showing  alopecia  and  osseous  depressions. 

first  in  patches.  The  skin  gets  thinner,  there  is  loss  of  pigment, 
hairs  fall  out,  and  the  areas  may  have  a  yellowish  appearance. 
Sometimes  the  periosteum  and  bone  are  affected,  and  shallow  de- 
pressions are  formed  which  may  be  anaesthetic  (Fig.  235).  The  sub- 
cutaneous tissue  is  most  involved,  the  muscles  suffer  least,  and  there 
are  no  changes  in  electrical  reaction.  The  muscles  of  mastication 
are  usually  spared.  The  bone  undergoes  general  atrophy  and  the 
lower  jaw  may  be  reduced  to  two-thirds  the  normal  size.  The  se- 
cretion of  sebum  ceases,  but  that  of  sweat  may  be  increased.     The 

*  About  100  cases  have  been  reported.  Among  5  seen  by  myself,  3  were 
in  females,  2  in  males.  The  disease  in  all  cases,  so  far  as  could  be  found, 
began  between  the  tenth  and  twentieth  years. 


THROPIC    AND   VASOMOTOR    DISORDERS. 


569 


temperature  falls.  There  are  a  sinking  in  of  the  eye,  narrowing  of 
the  lid,  and  dilatation  of  the  pupil.  There  is  sometimes  pain  and 
rarely  anaesthesia.  The  tongue  and  other  parts  of  the  body  may  be 
involved.  Spasmodic  movements  of  the  muscles  of  mastication  have 
been  noted  (B.  Sachs).  Scleroderma  sometimes  appears  on  the  face 
or  hands. 

The  disease  progresses  rather  rapidly  at  first,  but  finally  comes 
to  a  standstill.     It  does  not  shorten  life. 

Pathology. — There  has  been  found  a  degenerative  neuritis  in- 
volving the  fibres  of  the  trigeminus ;  its  descending  root  and  the 
substantia  nigra  were  atrophied  (Mendel). 

The  diagnosis  is  easy.     Hemiplegia  with  atrophy  in  children, 
congenital  asymmetry,   and   atrophy    from 
gross  lesions  of  the  nerve  are  distinguished 
by  their  stationary  character  or  the   pres- 
ence of  severe  pain. 

Treat  merit. — There  is  no  treatment 
known  to  be  of  service.  Tonics,  iodides, 
and  electricity  may  be  tried.  Dercum  has 
suggested  resecting  the  trigeminal  nerve. 

Progressive  Facial  Hemihyper- 
trophy  is  an  extremely  rare  condition, 
only  eleven  cases  having  been  reported. 
It  is  usually  congenital  in  origin,  but  may 
develop  in  connection  with  giantism,  as  in 
a  case  of  my  own  (Fig.  236). 


Fig.  236.  —Facial  Hemi- 
hypertrophy  occurring  ix 
a  Giant. 


Acromegaly  (Marte's  Disease). 

Acromegaly  is  a  chronic  dystrophy  characterized  by  gradual  en- 
largement of  the  hands,  feet,  head,  and  thorax,  and  by  a  dorso-cer- 
vical  kyphosis.  Though  the  disease  was  first  described  only  ten 
years  ago  by  P.  Marie,  the  number  of  cases  reported  is  rapidly 
increasing,  and  if  one  includes  various  abortive  types  it  is  not 
extremely  rare. 

Etiohxjj. — It  affects  the  two  sexes  nearly  alike.  It  begins  be- 
tween the  ages  of  eighteen  and  twenty-six;  recently  a  congenital 
case  has  been  reported.  No  hereditary  influence  or  definite  exciting 
cause  is  known.  The  patients  are  sometimes  naturally  endowed 
with  large  extremities. 

Symptoms,  -The  disease  begins  with  a  gradual  enlargement  of 
fche  hands,  feet,  and  head.  In  women  there  is  amenorrhea,  in  men 
sexual  weakness ;  slight  rheumatic  pains,  headaches,  malaise,  men- 
tal hebetude,  anaemia,  and  general  weakness  are  present.  The  skin  is 
dry  and  there  is  polyuria. 


570 


DISEASES    OF    THE    NERVOUS    SYSTEM. 


The  hypertrophy  affects  the  soft  parts  as  well  as  bones.  In 
these  latter  there  are  periosteal  thickening  and  hyperplasia,  with  the 
result  of  producing  increase  in  width  more  than  length.  The  arms 
are  not  inuch  involved,  nor  is  the  shoulder  girdle,  except  the  clav- 
icle. The  lower  jaw  is  much  more  involved  than  the  cranium.  The 
tongue,  lips,  and  nose  are  enormously  hypertrophied  (Fig.  237). 
The  thorax  is  enlarged  antero-posteriorly  and  flattened.  There  is 
sometimes  dulness  over  the  sternum  due  to  persistence  of  the  thymus. 
The  pelvis  may  be  enlarged,  but  the  hip  and  leg  bones  are  gener- 


Fig.  237.— The  Face  in  Acromegaly  (Curschman). 


ally  spared.  The  hands  and  feet  undergo  enormous  hypertrophy 
(Fig.  238).  The  following  are  some  of  the  measurements  in  the 
case  that  has  come  under  my  observation,  reported  by  Adler,  and  in 
cases  reported  by  Osborne  and  Packard : 


Length  of  hand, 
Length  of  foot, 
Cranial  circumference,     . 
Circumference  of  thorax, 


7.6  to    8f  inches. 
11.7  to  13i      " 
24     to  261      " 
44 


The  vision  is  sometimes  impaired  and  there  may  be  hemianopsia. 
The  muscles  may  be  at  first  hypertrophied,  later  atrophied.  There 
are  no  paralyses  and  rarely  any  anaesthesias. 

The  disease  runs  a  very  chronic  course,  lasting  ten  or  twenty 
years. 

Pathology. — There  has  been  found  an  enlargement  of  the  pitu- 


TROPHIC    AND    VASOMOTOR    DISORDERS.  571 

itary  body  in  nearly  all  cases,  and  it  is  probable  that  the  disease  is 
due  to  disorder  of  its  function.  The  attempts  to  place  the  disease 
in  relation  with  a  persistent  thymus,  sclerotic  changes  of  the  sym- 
pathetic, and  disease  of  the  thyroid,  all  of  which  conditions  have  been 
found,  are  unsuccessful.  The  disease  must  be  regarded  as  a  perver- 
sion of  nutrition  due  to  defective  action  of  the  pituitary  gland. 

The  diagnosis  must  be  made  from  congenital  enlargements,  from 
so-called  giant  growth  which  affects  single  members,  and  from  oste- 


Fig.  238.—  Normal  Hand  and  Hand  in  Acromegaly. 

itis  deformans.  In  the  latter  disease  it  is  the  shafts  of  the  long 
bones  and  the  cranium,  not  the  face,  which  are  involved. 

Pneumogenic  osteo-arthropathy  is  the  name  given  by  Marie  to  a 
disease  associated  with  pulmonary  and  pleuritic  disease,  and  charac- 
terized by  enlargement  of  the  extremities  and  peculiar  deformities 
of  the  terminal  phalanges.  The  enlargements  are  not  uniform. 
The  tongue  is  not  affected.  The  wrist  and  ankle  bones  are  hyper- 
trophied,  the  finger-tips  are  bulbous  and  spade  shaped. 

Prognosis. — Acromegaly  is  incurable,  but  it  has  been  arrested, 
or  at  least  has  ceased  to  progress,  and  it  may  not  greatly  shorten 
life. 

Treatment. — Cases  have  been  reported  in  which  iodide  of  potas- 
sium and  arsenic  have  arrested  the  disease.  In  general,  the  treat- 
ment is  only  symptomatic,  but  feeding  with  pituitary  gland  in 
large  doses  (gr.  xl. )  should  be  tried. 


572 


DISEASES   OF   THE    NERVOUS   SYSTEM. 


Myxcedema. 

Myxoedema  is  a  disease  of  the  thyroid  gland,  but  its  symptoms 
are  so  largely  nervous  that  a  brief  description  of  it  is  justified  here. 
It  is  a  chronic  disorder,  due,  as  a  rule,  to  an  interstitial  thyroiditis, 
and  characterized  by  a  solid  oedema  of  the  subcutaneous  tissue,  dry 
skin,  loss  of  hair,  subnormal  temperature,  mental  dulness,  and  even 
insanity  and  idiocy.     It  has  two  forms — the  congenital  and  infantile 


BIG.  239.— A  Case  of  Myxoedema  in  a  Man  aged  Forty-Four  Years  (Murray). 


— causing  a  condition  known  as  cretinism ;  and  an  adult  form  con- 
stituting myxcedema  proper. 

It  occurs  most  often  between  the  ages  of  thirty  and  fifty,  and 
oftener  in  women  (seven  to  one).  It  is  seen  oftenest  in  temperate 
climates.  Hereditary  influence,  alcoholism,  and  syphilis  are  not 
predisposing  factors ;  lead  poisoning  may  be  a  cause. 

It  begins  slowly.  The  patient  is  languid  and  dull,  and  is  un- 
usually sensitive  to  cold.  Voluntary  movements  are  slow;  the 
weight  increases  and  a  solid  oedema  which  does  not  dent  on  pressure 
develops  in  the  face  and  extremities.  The  skin  gets  dry  and  rough, 
the  hair  begins  to  fall,  the  temperature  is  subnormal,  1°  to  2°  F. 


TROPHIC   AND   VASOMOTOR   DISORDERS.  573 

Mentally  the  patient  is  dull,  forgetful,  depressed,  and  in  one-fifth 
of  the  cases  melancholia,  mania,  or  dementia  develops.  The  mus- 
cles are  weak,  the  gait  is  slow,  the  voice  hoarse  and  monotonous. 
There  is  considerable  anaemia  aud  the  heart  is  weak.  The  pulse  is 
slow  and  the  arterial  tension  low.  Albuminuria  is  present  in  twenty 
per  cent  of  cases,  and  hemorrhages  may  occur. 

The  pallor,  oedema,  loss  of  hair,  and  mental  hebetude  give  to 
the  face  a  characteristic  expression  (Fig.  239).  The  disease  may 
run  a  course  of  six  or  seven  years,  the  patient  dying  of  cardiac 
weakness  or  some  intercurrent  malady. 

The  disorder  is  due  in  most  cases  to  a  chronic  interstitial  thy- 
roiditis which  usually  causes  atrophy  of  the  gland.  It  may  be 
produced  by  artificial  removal  of  the  thyroid.  The  result  of  this  is 
a  defective  action  of  the  thyroid,  and  a  consequent  poisoning  of 
the  system  and  deposit  of  mucin  in  the  subcutaneous  tissue  espe- 
cially. 

The  diagnosis  is  based  upon  the  peculiar  physiognomy  due  to 
the  oedema  pallor ;  the  loss  of  hair,  subnormal  temperature,  mental 
hebetude,  and  atrophied  thyroid. 

The  prognosis  is  good  if  treatment  is  instituted. 

The  treatment  consists  in  the  administration  of  the  thyroid  ex- 
tract in  daily  doses  ranging  from  five  to  forty  grains  or  even  more. 
The  results  are  most  brilliant,  and  humanity  owes  much  to  Dr. 
George  R,  Murray,  who  first  instituted  it. 

Cretinism. 

Cretinism  is  a  form  of  myxoedema  due  to  absence,  atrophy,  or  de- 
fective function  of  the  thyroid  gland,  occurring  congenitally  or  dur- 


Krv 


%k   isJ^f 


fc 


Fig.  210.— A  Cretin  Dwarf,  aged  Twenty  CLeszyaslry). 

ing  infantile  life.     The  disease  occurs  endemically  in  parts  of  Eu- 
rope, but  only  sporadically  and  happily  with  great  rarity  in  America. 


574 


DISEASES    OF   THE    NERVOUS    SYSTEM. 


Hereditary  and  family  influences  are  at  work  in  endemic  but  not  in 
sporadic  cretinism.  It  develops  either  directly  after  or  in  the 
first  three  years  of  life,  and  shows  itself  in  a  stunted  growth  both 
of  brain  and  body,  most  cretins  being  idiotic  dwarfs.  The  general 
symptoms  are  much  like  those  of  myxcedema  in  adults  plus  the 
retarded  growth  of  mind  and  body.  The  deposits  of  solid  oedema 
cause  peculiar  deformities  and  lead  to  a  characteristic  physiognomy. 


Fig.  211. —Sporadic  Cretinism  in  a  Patient  aged  Twenty-eight;  Height,  84J4  Inches 

(Murray). 

The  mind  is  dull  and  placid,  the  muscles  are  weak,  the  abdomen 
is  protuberant,  the  hands  and  feet  are  broad  and  thick ;  the  patients 
are  anaemic,  the  temperature  is  subnormal.  The  arrested  bodily 
growth  is  such  that  on  reaching  adult  age  the  stature  may  be  only 
twenty -eight  to  thirty -three  inches  (Fig.  241). 

Cretins  usually  die  young,  but  some  survive  to  the  age  of  thirty 
or  forty. 


TKOPHIC    AND    TASOMOTOK    DISORDERS.  575 

The  treatment  is  the  same  as  that  of  myxcedema.  Here,  too,  if 
the  case  is  seen  before  adolescence,  brilliant  results  can  be  obtained. 

Axgio-Neurotic   (Edema  (Circumscribed  (Edema). 

Angio-neurotic  oedema  is  a  functional  disorder  characterized  by 
the  rather  rapid  appearance  of  circumscribed  swellings  upon  differ- 
ent parts  of  the  body,  these  swellings  being  due  to  disturbances  of 
vasomotor  innervation  and  not  of  an  inflammatory  character.  The 
disease  occurs  ofteuest  in  early  adult  life,  the  average  age  being 
from  twenty  to  thirty,  but  it  has  been  observed  in  young  children 
and  even  in  the  aged.  It  occurs  oftener  in  males  than  in  females, 
except  in  this  country,  where  the  reverse  ratio  exists.  Hereditary 
influence  plays  a  part  in  some  cases ;  the  disease  has  been  known  to 
run  in  families.  It  occurs  oftener  in  winter  and  oftener  in  the  early 
morning  hours.  Exhausting  occupations  predispose  to  it.  The  ex- 
citing causes  are  sudden  exposure  to  cold,  slight  traumatisms,  fright, 
anxiety,  grief,  and  the  ingestion  of  certain  kinds  of  food  such  as 
apples  or  fish.  A  peculiar  form  of  this  oedema  seems  to  develop  in 
connection  with  menstruation. 

Symptoms. — The  disease  appears  without  much  if  any  warning. 
In  a  few  minutes  or  hours  there  develops  a  circumscribed  swelling 
upon  the  face  or  arms  or  hands.  This  swelling  varies  in  diameter 
from  one-half  inch  to  two  or  three  inches.  It  may  be  dark  reddish 
or  rosy  or  it  may  be  pale  and  waxy.  It  does  not  easily  pit  on  pres- 
sure. There  is  sometimes  a  local  rise,  sometimes  a  fall  in  tempera- 
ture. It  is  accompanied  by  sensations  of  tension  and  stiffness,  scald- 
ing, burning,  and  sometimes  itching,  but  there  is  no  actual  pain. 
The  swelling  is  usually  single,  but  it  may  be  multiple.  It  is  located 
most  often  upon  the  face,  next  upon  the  extremities,  particularly  the 
hands ;  next  on  the  body,  then  in  the  larynx  and  throat,  and  then 
on  the  genitals.  The  swellings  last  from  a  few  hours  to  two  or 
three  days.  Between  the  attacks  the  patient  feels  well.  They  are 
apt  to  return  at  intervals  of  three  or  four  weeks  to  several  months. 
Sometimes  they  are  brought  out  only  by  certain  peculiar  exciting 
causes,  such  as  indigestion  or  mental  anxieties  or  emotional  disturb- 
ances. When  the  disease  attacks  the  larynx  or  throat,  serious 
symptoms  of  dyspnoea  and  suffocation  may  appear;  surgical  inter- 
ference may  even  be  called  for,  and  death  has  been  known  to  re- 
sult. It  has  been  thought  that  neurotic  oedema  may  sometimes  at- 
tack the  stomach,  producing  symptoms  of  nausea,  vomiting,  and  great 
gastro-intestinal  distress,  and  an  acute  neurotic  oedema  possibly  some- 
times attacks  the  lungs.  This,  however,  is  unlikely,  since  the  vaso- 
motor innervation  of  the  pulmonary  blood-vessels  is  a  very  stable  one. 


576  DISEASES  OF  THE   NERVOUS  SYSTEM. 

The  pathology  of-  the  disease  is  not  known,  except  that  it  is  un- 
questionably a  disorder  due  primarily  to  disturbance  in  nerve  inner- 
vation. The  nerves  affected  are,  farthermore,  undoubtedly  vaso- 
motor nerves.  The  oedema  is  precisely  similar  to  that  which  is 
associated  with  attacks  of  tic  douloureux  and  migraine. 

Diagnosis. — The  symptoms  of  the  disease  are  so  peculiar  that 
they  are  easily  recognized.  The  spontaneous  appearance  of  the 
oedema,  its  recurrence  at  certain  intervals,  and  the  absence  of  pain 
and  evidences  of  inflammation  are  sufficient  usually  to  enable  us  to 
recognize  it.  The  giant  urticaria  is  a  disease  resembling  neurotic 
oedema  and  probably  closely  allied  to  it.  The  blue  and  the  white 
oedema  of  hysterics  differs  in  being  persistent  and  associated  with 
paralyses,  anaesthesias,  and  contractures. 

The  prognosis,  so  far  as  cure  is  concerned,  is  not  very  good. 
The  attacks,  however,  can  be  ameliorated,  and  the  disease  itself  is 
not  serious  as  regards  life  and  the  enjoyment  of  a  fair  degree  of 
general  health. 

The  treatment  consists  in  the  adoption  of  such  measures  as  will 
give  tone  and  stability  to  the  nervous  system ;  the  use  of  cold  baths, 
exercise,  and  massage  is  indicated.  Internally  mineral  acids  and 
strychnine  may  be  of  some  value.  Cascara,  nux  vomica,  the  salicy- 
lates, arsenic,  quinine,  and  atropine  are  all  drugs  which  have  been 
recommended. 


CHAPTER   XXIX. 

THE    DISORDERS    OF    SLEEP. 

Insomnia,   Hypnotism,   Morbid    Somnolence,    Catalepsy, 
Trance,   Lethargy,   the  Sleeping  Sickness. 

Sleep  is  a  condition  in  which  consciousness  is  normally  lost  and 
in  which  the  whole  body,  but  particularly  the  brain,  enjoys  func- 
tional rest,  while  constructive  and  nutritive  activity  goes  on. 

Physiology. — The  most  conspicuous  phenomenon  of  sleep  is  the 
subsidence  of  the  higher  cerebral  functions;  yet  other  organs,  nota- 
bly the  muscular  system,  also  take  part  in  the  resting-process. 
The  brain  during  sleep  is  slightly  anaemic,  the  deficiency  in  blood 
being  a  part  of,  but  not  the  cause  of,  the  phenomenon.  The  remote 
cause  of  sleep  is  inherent  in  the  nervous  tissue  itself,  which  follows 
the  great  rhythmical  law,  common  to  all  living  tissue,  of  rise  and  fall 
in  its  irritability.  It  is  probable  that  the  immediate  cause  of  drow- 
siness is  the  exhaustion  of  the  irritability  of  the  cortical  cells  and 
the  benumbing  of  them  by  the  circulation  of  waste  products  in  the 
blood.  Many  facts  in  the  history  of  the  pathology  of  the  brain 
point  to  the  existence  of  a  sleep  centre,  which,  being  especially 
acted  upon,  tends  to  inhibit  the  consciousness  and  draw  the  mind 
into  a  somnolent  state. 

As  sleep  is  only  a  function,  we  cannot  speak  of  its  diseases,  but 
only  of  its  disorders,  and  these  really  form  but  a  part  of  the  dis- 
eases of  the  brain  or  of  general  diseases.  It  is  a  matter  of  conven- 
ience, however,  to  discuss  some  of  these  separately. 

Classification. — Custom  has  established  the  use  of  certain  terms 
for  the  various  disorders  of  sleep,  and  such  terms  must  be  foi  the 
most  part  adhered  to.  It,  will  be  proper,  however,  for  the  sake  of 
completeness,  t<»  arrange  the  various  disturbances  we  are  to  discuss 
in  accordance  with  the  modern  methods  of  studying  the  pathological 
changes  of  bodily  functions.  We  propose,  therefore,  the  following 
classification,  which  indicates  the  various  depressions,  exaltations, 
and  perversions  of  the  functions  of  sleep: 

I.  Stale  of  normal  slic])      Hypnosis.      Somnns. 
II.  States  of  absence  of  sleep.    Ahyp-      Insomnia. 
?to*i«. 
37 


578  DISEASES    OF   THE   NERVOUS   SYSTEM. 

III.  States  of  perverted  or  artificial      Dreams,    nightmare,   night    terrors, 

sleep.     Parahypnosis.  sleep-drunkenness,  somnambulism, 

hypnotism. 

IV.  States  of  excessive  or  frequent      Morbid   somnolence,  paroxysmal 

drowsiness  and  sleep.     Hyper-         sleep,    epileptic    sleeping-attacks, 
hypnosis.  trance  sleep,  lethargy,  sleeping- 

sickness  of  Africa. 

I.  Normal  sleep  varies  much  in  accordance  with  age,  sex,  the 
individual,  and,  to  a  slight  extent,  with  occupation,  race,  and  cli- 
mate. The  infant  sleeps  fourteen  or  sixteen  hours  out  of  the  twenty - 
foui,  the  adult  needs  about  eight  hours,  while  the  aged  live  health- 
fully with  but  six.  Women  need  half  an  hour  or  an  hour  more  than 
men.  A  few  persons,  generally  men,  need  nine,  ten,  or  even  twelve 
hours  of  sleep  daily ;  others  require  only  six.  Brain  workers,  as  a 
class,  take  less  sleep  than  laborers.  Sleep  is  sounder  and  longer  in 
cold  climates  and  among  northern  races. 

II.  Insomxia  is  a  term  given  to  conditions  in  which  persons 
simply  suffer  from  insufficient  and  restless  sleep  or  from  entire  ab- 
sence of  sleep  for  a  long  time.  Such  conditions  result  from  a  great 
variety  of  causes.  It  is  my  purpose  to  discuss  only  those  forms  in 
which  the  trouble  is  functional  or  nutritional,  leaving  out  of  consid- 
eration the  symptomatic  insomnia  of  organic  brain  disease  and  that 
occurring  as  the  result  of  painful  diseases. 

An  entire  absence  of  the  capacity  to  sleep  occurs  most  often  and 
typically  at  the  onset  or  in  the  course  of  insanity.  It  is  here  a 
prominent  and  most  distressing  symptom.  The  length  of  time  dur- 
ing which  a  person  can  live  without  any  sleep  is  about  the  same  as 
that  during  which  he  can  go  without  food,  viz.,  three  weeks.  Many 
hysterical,  neurasthenic,  or  incipiently  insane  individuals  will  assert 
that  they  have  not  slept  for  weeks,  but  careful  examination  shows 
that  they  have  at  least  been  in  a  drowsy,  somnolent  condition,  which 
is,  in  a  measure,  physiologically  equivalent  to  sleep. 

Etiology. — The  cases  in  which  persons  can  get  only  a  troubled 
rest  of  a  few  hours  are  much  more  numerous.  It  is  a  disorder  of 
the  third,  fourth,  and  fifth  decades  of  life.  Women  are  less  liable 
to  suffer  from  it  than  men,  and  the  laboring  classes  less  than  those 
engaged  in  business  or  professional  pursuits.  A  frequent  symptom 
of  neurasthenia  is  an  imperfect,  and  especially  an  unresting,  sleep. 
In  gout  and  in  the  so-called  latent  gout,  or  lithsemia,  insomnia  is  a 
frequent  symptom.  One  of  the  few  nervous  symptoms  of  secondary 
syphilis  is  insomnia.  Insomnia  may  develop  as  a  bad  nervous  habit 
in  persons  who  are  neglectful  of  themselves.  It  occurs  sometimes 
as  an  hereditary  neurosis.  I  am  acquainted  with  a  family  in  which, 
for  four  generations,  one  or  more  of  the  members  have  suffered  from 


THE    DISOKDERS    OF    SLEEP.  579 

chronic  insomnia  throughout  life.  In  anaemia  and  chlorosis  there 
is  often  insomnia  at  night,  combined  with  somnolence  during  the 
daytime.  Disease  of  the  heart  and  arteries  may  lead  to  insomnia, 
and  under  this  head  come  the  cases  which  occur  in  Blight's  disease 
with  tense  arteries  and  anaemic  brains.  Disorders  of  the  stomach 
lead  to  disturbed  sleep  oftener  than  to  complete  insomnia,  and  the 
liver,  when  inactive,  causes  somnolence  rather  than  the  contrary. 
The  poison  of  malaria  and  the  toxic  agents  of  fever  must  be  added 
to  the  list  of  causes  of  imperfect  sleep. 

It  will  be  seen  that  the  causes  of  chronic  functional  insomnia 
may  be  classed  under  the  following  heads : 

1.  Neurasthenic  and  vasomotor,  including  hereditary  and  habit 
insomnia. 

2.  Vascular  and  cardiac,  including  heart  disease,  arterial  fibrosis, 
and  general  anaemia. 

3.  Auto-toxic  or  diathetic,  including  lithaemia,  gout,  and 
uraemia. 

4.  Toxic,  including  syphilis,  lead,  malaria,  tobacco,  and  various 
drugs,  such  as  coffee,  tea,  and  cocoa. 

In  many  cases  there  exists  a  combination  of  these  causes. 

Symptoms. — The  forms  and  degrees  of  insomnia  vary  greatly. 
In  children  it  is  accompanied  usually  by  much  mental  and  physi- 
cal disturbance.  The  patient  is  restless,  excited,  talkative,  or  quer- 
ulous and  irritable.  The  insomnic  child  is  more  ill  than  the  insom- 
nic  adult.  In  neurasthenic  insomnia  there  is  a  tumult  of  thoughts 
which  prevent  sleep,  or  sleep  is  superficial,  unresting,  and  inter- 
rupted  by  dreams.  In  many  cases  of  insanity  insomnia  is  char- 
acterized by  great  motor  restlessness.  In  old  people  insomnia  is 
generally  of  the  quiet  kind. 

Treatment. — As  insomnia  in  all  its  phases  is  often  a  symptom  of 
some  general  disorder,  treatment  of  a  curative  kind  must  be  directed 
to  this.  Anaemia,  lithaemia,  uraemia,  malaria,  and  the  other  toxic 
influences  must  be  removed  by  remedies  adapted  to  these  conditions. 
But  besides  constitutional  treatment  there  is  a  symptomatic  treat- 
ment which  Avill  be  discussed  here,  premising,  however,  that  while 
there  are  many  sleep-producing  medicines  there  are  no  good  drugs 
for  insomnia. 

The  older  physicians  in  treating  sleeplessness,  used  to  depend 
largely  on  hyoscyamus,  camphor,  opium,  and  the  fetid  drugs,  such 
as  asafoetida,  musk,  and  valerian.  Hyoscyamus  is  still  used.  It  is 
to  be  given  in  large  doses,  such  as  five  or  ten  grains  of  the  extract, 
or  even  more,  and  from  ten  to  twenty  drops  of  the  fluid  extract. 
The  hydrobromate    of   hyoscine,   in    doses  of  gr.  -j-^j-  to  gr.  ^  or 


580  DISEASES   OF   THE    NERVOUS   SYSTEM. 

more,  is  one  of  the  best  forms.  Hyoscineis  indicated  in  the  insom- 
nia of  the  insane,  especially  in  forms  accompanied  by  motor  ac- 
tivity. Chloral  hydrate  still  holds  its  own  as  one  of  the  surest  of 
hypnotics.  The  dangers  involved  in  its  use  have  been  somewhat 
exaggerated,  though  they  are  sufficiently  real.  Doses  of  gr.  x.  and 
gr.  xv.  are  often  quite  large  enough,  but  in  alcoholic  insomnia  it 
may  be  given  in  twice  the  above  amounts,  guarded  with  ammonia 
and  digitalis.  Not  a  few  persons  find  that  chloral  has  bad  effects. 
The  patient  awakes  with  a  dull,  heavy  sensation  in  the  head,  slight 
headache,  or  gastric  disturbance. 

The  various  bromides  are  efficient  and  safe  hypnotics  if  properly 
used.  The  immediate  effect  of  them  is  simply  sedative,  and  sleep 
is  not  produced  unless  very  large  doses  are  given.  Some  persons 
are  even  kept  awake  by  average  doses  (gr.  xv.  to  xx.).  In  insom- 
nia, therefore,  bromides  are  best  prescribed  in  closes  of  gr.  xv.  three 
times  a  day.  By  the  second  evening  sleep  is  generally  secured. 
The  bromide  habit  is  rarely  formed,  and  is  in  itself  not  so  seriously 
injurious  as  the  choloral  or  opium  habit.  The  bromides  alone  are 
hardly  strong  enough  hypnotics  for  alcoholic  insomnia  or  the  insom- 
nia of  insanity.  I  have  found  them  to  fail  in  the  insomnia  of  the 
aged.  Paraldehyde  ranks  close  to  chloral  in  its  value  as  a  hypnotic, 
[n  some  persons  it  disturbs  the  stomach,  but  not  in  all,  and  it  may 
be  used  as  a  hypnotic  for  months  without  its  power  being  impaired. 
It  is  a  disagreeable  drug,  and  there  is  nothing,  so  far  as  I  know, 
that  palliates  its  offensiveness.  I  prefer,  however,  to  prescribe  it 
in  3  i.  doses  poured  upon  a  teaspoonful  of  powdered  sugar.  Doses 
of  3  ss.  are  sufficient  to  cause  sleep  in  many  cases,  and  collapse  may 
be  caused  by  3  ij.  given  to  weak  patients.  Urethane,  in  doses  of  a 
scruple  or  more,  is  a  mild  and  agreeable  hypnotic,  but  not  so  certain 
as  paraldehyde.  Amylene  hydrate  is  a  hypnotic  of  properties 
similar  to  those  of  paraldehyde,  but  less  disagreeable.  It  is  given  in 
doses  of  about  one  drachm.  Lupulin  in  large  doses,  gr.  x.  to  gr. 
xx.,  is  a  good  hypnotic.  Suiphonal  in  closes  of  gr.  x.  to  gr.  xxx. 
given  two  or  four  hours  before  retiring  is  one  of  the  best  hypnotics. 
Chloral-amide  is  more  agreeable  and  safer  than  chloral,  though 
it  acts  practically  in  the  same  way.  The  close  is  3  i.  to  3  ij. 
Tiional  in  doses  of  gr.  xv.  is  rather  better  than  suiphonal. 

Among  the  antispasmodics  are  several  drugs  which  occasionally 
answer  well  in  the  insomnia  due  to  nervous  irritability.  A  drachm 
of  the  fluid  extract  of  valerian  or  of  spirits  of  lavender,  for  example, 
may  be  prescribed.  In  some  forms  of  insomnias — perhaps  best  in 
those  due  to  fever,  or  pain,  or  some  rheumatic  or  gouty  trouble— 
antipyrin  in  twenty-grain  doses  acts  well.     It  is  known  that  in 


THE    DISORDERS    OF    SLEEP.  581 

many  cases  of  mild  types  of  insomnia  a  dose  of  whiskey,  brandy,  or 
beer  will  put  the  patient  to  sleep. 

Besides  drugs,  there  are  many  hygienic  or  mechanical  measures 
to  which  the  physician  may  successfully  resort — listening  to  monot- 
onous noises,  reading  dull  or  heavy  books,  counting,  or  keeping  be- 
fore the  fancy  some  blank  or  wearying  picture — ■ 

"  A  flock  of  sheep  that  leisurely  pass  by 
One  after  one  ;  the  sound  of.  rain  and  bees 
Murmuring  ;  the  fall  of  rivers,  winds  and  seas, 
Smooth  fields,  white  sheets  of  water,  and  pure  skies.  " 

Mechanical  remedies  have  nearly  all  for  their  purpose  the 
withdrawal  of  the  blood  from  the  brain  to  the  skin  and  abdominal 
viscera.  Hot  footbaths  or  warm  general  baths,  cold  douches  down 
the  spine,  beating  the  limbs  with  rubber  hammers,  brisk  exercise,  a 
light  meal,  massage,  all  are  at  times  efficient  hypnotics.  Persons 
who  suffer  from  insomnia  should  sleep  in  cold  rooms,  the  head  should 
not  be  too  high  or  very  low,  and  in  most  cases  they  are  better 
without  late  suppers,  even  though  these  be  light.  Mental  work 
should  be  laid  aside  several  hours  before  retiring,  and  the  evening 
devoted  to  quiet  conversation  and  reading  or  amusements  that  do 
not  actively  excite  the  nerves.  Many  persons  live  in  good  health 
though  they  sleep  in  the  day  and  stay  awake  at  night.  Journalists 
and  editors,  whose  work  obliges  them  to  go  to  bed  in  the  early 
morning,  often  continue  for  years  without  impairment  of  physical 
vigor.  Despite  this,  it  is  true  that  the  besl  time  for  sleep  is  at  night, 
and  that  the  old  maxim,  "  Early  to  bed,"  is  a  sound  one.  Vet  it  is 
not  the  early  bird  that  gets  the  worm  so  much  as  the  bird  that  lias 
slept  well.  The  human  system  requires  a  certain  amount  of  sleep  and 
should  have  it.  The  industrious  and  ambitious  often  try  to  train 
themselves  to  shorter  hours,  but  though  they  may  succeed  for  a  time, 
nature  will  not  be  cheated  out  of  her  due  and  health  suffers  in  the 
end.  It  is  a  widespread  custom  in  some  countries  to  take  a  short 
nap  in  the  daytime,  and  the  custom  is  a  good  one.  America  has 
m»t,  adopted  it,  but  might  do  so  with  benefit,  to  the  health  of  her 
brain-working  class.  Many  from  childhood  up  do  not  get  a  suffi- 
cient amount  of  sleep. 

111.    Perversions  and  Disturbances  of  Sleep.     Sleep  is  said 

to  reach  its  deepest,  stage  in  from  one  to  two  hours  after  if,  begins. 
There  is  then  after  this  a  gradual    lessening  of   the   depth  of  sleep. 

Probably  there  are  great  variations  in  tins  rule,  for  many  persons 
seem  in  soundest  slumber  several  hours  niter  falling  asleep.  But, 
at  any  rate,  there  are  lighter  stages  of  sleep  at  its  inception  and 


582  DISEASES   OF   THE   NERVOUS    SYSTEM. 

toward  its  end.  These  are  the  favorite  times  for  dreams,  and  at 
this  period  also  there  develop  the  peculiar  phenomena  of  sleep 
drunkenness. 

Dreams,  Nightmare. — When  sleep  is  perfect  and  profound, 
dreams  afterward  remembered  do  not  occur.  Dreaming  is,  there- 
fore, a  morbid  symptom,  although  often  of  trivial  significance,  es- 
pecially if  it  occurs  at  about  the  time  of  natural  waking,  when  slum- 
ber is,  in  its  physiological  course,  passing  into  the  lighter  stages.  In 
sleep,  no  matter  how  light,  the  action  of  the  regulating  centre  which 
directs  thought,  controls  emotion,  and  exhibits  itself  in  volition  is 
suspended;  the  psychical  mechanism,  if  excited  to  action  at  all, 
works  without  purpose,  like  a  rudderless  ship  at  sea.  Ideas  and 
emotions  succeed  each  other  by  the  laws  of  association,  but  are  not 
properly  correlated,  and  judgment  and  logical  reasoning  are  gone. 
As  a  rule,  dreams  are  made  up  of  somewhat  ordinary  ideas  and 
fancies  incoherently  associated,  and  shifting  too  rapidly  to  call  up 
much  feeling.  When  from  some  point  in  the  body  painful  sensory 
excitations  do  produce  disagreeable  images,  emotions  of  a  most  vio- 
lent kind  may  be  felt. 

In  the  earlier  stages  of  civilization,  among  primitive  people, 
dreams  were  comparatively  rare.  When  they  did  come  with  vivid- 
ness they  were  regarded  with  importance,  and  often  were  considered 
visitations  of  spirits.  Civilized  man  dreams  more,  but  he  has  learned 
to  treat  his  fancies  with  corresponding  indifference.  The  attempts 
of  scientific  men  to  formulate  laws  regarding  them  have  been  pro- 
ductive of  small  results.  Some  diseases,  however,  cause,  as  a 
rule,  dreams  of  a  more  or  less  peculiar  kind.  Thus  heart  disease 
is  accompanied  by  dreams  of  impending  death.  Previous  to  at- 
tacks of  cerebral  hemorrhage  patients  have  dreamed  of  experienc- 
ing some  frightful  calamity  or  of  being  cut  in  two.  Intermittent 
fever  is  often  announced  by  persistent  dreams  of  a  terrifying  char- 
acter. Hammond  has  collected  a  large  number  of  what  he  terms 
prodromic  dreams,  all  going  to  show  that  before  recognizable  signs 
of  disease  are  present  morbid  dreams  of  various  kinds  may  occur. 
Albers  says:  "Frightful  dreams  are  signs  of  cerebral  congestion. 
Dreams  about  fire  are,  in  women,  a  sign  of  impending  hemorrhage. 
Dreams  about  blood  and  red  objects  are  signs  of  inflammatory  con- 
ditions. Dreams  of  distorted  forms  are  frequent^  a  sign  of  abdom- 
inal obstructions  and  diseases  of  the  liver." 

Nightmare  is  a  disorder  incident  to  the  hypohypnotic  state,  or 
that  of  incomplete  sleep.  It  is  one  of  those  minor  ills  that  are 
nearly  always  symptomatic  of  an  irritation  in  some  part  of  the 
body.     The  usual  causes  of  it  are  some  digestive  disturbance  (re- 


PLATE  III. 


NERVOUS    DISEASES. 

Dana 


COMPOSITE  PHOTOGRAPH   SHOWING  RELATIONS  OF  CRANIAL  SURFACE  TO  THE 
FISSURES  AND  CONVOLUTIONS  (  Alec  Fraser  ). 


THE    DISORDERS    OF    SLEEP.  583 

pletion)  and  cardiac  disease.  Persons  of  a  nervous  temperament 
are  more  subject  to  it;  and  there  are  individuals  whom  it  makes 
suffer  all  their  lives.  The  popular  belief  that  sleeping  on  the  back 
favors  it  is,  in  general,  a  correct  one.  When  nightmare  occurs  in 
cardiac  disease  a  certain  position,  semirecumbent  or  on  the  right  side, 
must  be  maintained,  or  the  painful  fancies  will  awaken  the  patient. 
Healthy  people  can  get  sound  sleep  whether  lying  upon  the  back, 
the  side,  or  the  stomach;  but  light  sleepers,  and  those  with  sensi- 
tive abdominal  viscera,  generally  find  that  the  position  on  the  right 
side  is  the  most  comfortable  and  less  provocative  of  unpleasant 
dreams.  Prolonged  mental  or  physical  strain,  excitement,  and 
worry  predispose  to  nightmare.  Farinaceous  foods,  excessive 
use  of  strong  liquors,  coffee,  and  tobacco,  all  have  a  similar 
tendency.  Nightmare  occurs  also  in  anaemia  and  malaria,  and 
it  may,  in  fine,  be  excited  by  morbid  conditions  in  any  part  of  the 
body.  It  sometimes  occurs  about  the  menstrual  period  in  women. 
Its  most  common  feature  is  a  sense  of  suffocation  or  impending 
death. 

Pavor  nocturnus,  or  night-terrors,  is  a  sleep  disorder  peculiar  to-' 
children.  It  is  allied  to  nightmare  on  the  one  hand  and  sleep-drunk- 
enness on  the  other.  It  differs  from  the  former  condition  in  that 
the  child  continues  to  suffer  from  the  distressing  fancies  for  some- 
time after  he  is  awake.  Night-terrors  occur  usually  one  or  two- 
hours  after  sleep  has  begun.  The  child  wakes  up  screaming  with 
fright,  and  perhaps  runs  about  the  room  or  seeks  its  parents  for 
protection  against  some  imagined  harm.  The  disorder  occurs  in 
weakly,  anaemic,  nervous,  or  rheumatic  children.  It  is  clue  some- 
times to  lithaemia,  or,  as  the  older  writers  put  it,  rheumatism  or 
gout  of  the  brain.  Digestive  disturbances,  worms,  dentition,  he- 
reditary syphilis,  mental  strain,  fright,  and  excitement  are  placed 
among  the  causes.  It  sometimes  appears  to  be  a  paroxysmal  neu- 
rosis allied  to  epilepsy.  The  disorder  is  usually  harmless  and  the 
prognosis  favorable. 

Somnolentia,  or  sleep-drunkenness  (^Sehlaftrunken),  is  a  condi- 
tion of  incomplete  sleep  in  which  a  part  of  the  faculties  is  abnor- 
mally excited  while  the  other  is  buried  in  repose.  It  is  a  kind  of 
acted  nightmare.  The  person  affected  is  incoherent,  excited,  and 
often  violent.  He  experiences  the  delusion  of  some  impending 
danger,  and  while  under  it  acts  of  violence  have  been  committed. 
The  condition  is  one  of  medico-legal  importance,  therefore,  and  has 
been  discussed  by  writers  on  that  science  (Wharton  and  Still£). 
Minor  degrees  of  it  are  often  noticed  in  children  and  in  adults  who 
are  roused  from  a  very  profound  sleep.     It  at  times  Lecomes  a  habit,. 


584  DISEASES   OF   THE    NERVOUS    SYSTEM. 

and  a  most  annoying  or  dangerous  one.  The  disorder  in  its  severe 
form  is  fortunately  very  rare. 

The  treatment  of  morbid  dreams,  nightmare,  and  pavor  noe- 
turnus  must  be  directed  to  a  removal  of  the  causes.  Tonics,  cardiac 
stimulants,  laxatives,  antirheumatics,  attention  to  diet,  are  called 
for  according  to  the  condition  of  the  patient.  Change  in  surround- 
ings is  often  necessary.  Among  symptomatic  remedies  the  bromides 
are  the  best,  except  in  iithaemia,  when  alkalies  and  salicylates  may 
prove  more  serviceable.  In  somnolentia  the  patient  should  be  pre- 
vented from  getting  into  too  profound  sleep.  He  may  be  awakened 
once  or  twice  during  the  night,  or  take  a  nap  in  the  daytime.  The 
head  in  sleeping  should  be  raised  high  and  the  body  not  too  heavily 
covered. 

Somnavibulism. — Somnambulism  is  a  condition  similar  to  hyp- 
notism or  the  mesmeric  state.  In  it  volition  is  abolished  and  the 
mind  acts  automatically  under  the  dominance  of  some  single  idea. 
It  is  an  acted  dream.  Sight,  hearing,  and  nearly  all  the  avenues  of 
sense  are  closed.  The  sleepwalker  avoids  obstacles  and  performs 
ordinary  acts  automatically,  like  an  absent-minded  man,  which  in 
reality  he  is.  All  those  mechanisms  which  have  been  trained  by 
constant  repetition  to  act  automatically,  like  that  which  preserves 
equilibrium,  are  active,  and  their  powers  may  even  be  heightened,  so 
that  the  somnambulist  may  walk  along  roofs  or  on  dangerous  roads 
and  thread  intricate  passages  without  harm.  The  automatism  of 
the  somnambulist  may  continue  for  hours,  until  a  journey  has  been 
performed  or  a  task  completed.  He  may  carry  out  with  success 
familiar  mathematical  calculations,  write  a  letter,  or  work  upon  a 
picture,  but  he  only  follows  along  the  lines  established  by  constant 
iteration  in  his  waking  moments.  He  can  originate  nothing  new. 
He  is  roused  from  his  state  with  difficulty,  and  when  out  of  it  he 
remembers  nothing  of  what  has  occurred. 

Somnambulism  usually  arises  from  overeating.  Sleeping  with 
the  head  too  low  is  another  cause.  Violent  emotions  act  indirectly 
by  disturbing  digestion.  The  habit  being  once  established,  how- 
ever, attacks  occur  without  apparent  cause.  The  disorder  occurs 
oftenest  in  young  people  about  the  age  of  puberty,  and  it  then  at- 
tacks the  sexes  alike.  Later  in  life  women  are  more  often  affected. 
The  disease  is  fostered  sometimes  at  school  by  the  attentions  of  the 
schoolmates.  In  most  cases  a  condition  of  morbid  sensitiveness  un- 
derlies it.  The  patients  are  neurotic.  Hereditary  somnambulism 
has  been  observed.  Its  attacks  have  alternated  with  those  of  cata- 
lepsy. They  are  likely,  after  a  time,  to  become  periodical,  occur- 
ring every  week,  fortnight,  or  month.     The  somnambulic  state  may 


THE    DISORDERS   OF    SLEEP.  585 

come  upon  a  person  in  the  daytime.  It  is  then  regarded  as  spon- 
taneous trance,  or  hypnotism.  It  is  not  the  case,  however,  that 
persons  who  are  easily  hypnotized  are  usually  somnambulists, 
though  the  reverse  may  be  true. 

Somnambulism  is  a  term  that  should  include  not  only  sleep 
walking  but  sleep  talking. 

The  treatment  of  somnambulism  is  very  much  like  that  for  sleep 
drunkenness.  The  patient's  surroundings  must  be  investigated, 
and  unfavorable  influences,  such  as  may  occur  at  school  or  from 
injudicious  nurses,  be  removed.  He  should  be  prevented  from 
sleeping  too  soundly,  the  head  should  be  raised,  the  clothing  light, 
the  diet  regulated.  Remedies  like  iron,  quinine,  phosphorus,  and 
cod-liver  oi]  may  be  given.  When  the  patient  is  discovered  in  the 
somnambulistic  state  he  should  not  be  awakened,  or  at  least  not 
xmtil  he  is  safely  back  in  bed. 

Hypnotism,  Tkaxce,  Mesmerism. — Mmjor  hypnotism  is  a  mor- 
bid mental  state  artificially  produced  and  characterized  by  (1)  per- 
version or  suspension  of  consciousness ;  (2)  abeyance  of  volition ;  (3) 
a  condition  of  suggestibility  leading  the  patient  to  yield  readily  to 
commands  or  external  sense  impressions;  and  (4)  intense  concen- 
tration of  the  mental  faculties  upon  some  idea  or  feeling. 

Minor  hypnotism  is  a  state  closely  bordering  on  normal  sleep  in 
which  there  is  a  lowering  of  consciousness  and  a  condition  of  sug- 
gestibility. 

The  proportion  of  persons  of  all  ages  found  by  Beannis  to  be  hyp- 
notizable  was  about  eighteen  or  twenty  per  hundred.  Children  up  to 
the  age  of  fourteen  are  very  susceptible.  After  the  age  of  fifty-five 
susceptibility  lessens.  Men  are  almost  as  easily  affected  as  women; 
but  persons  of  a  docile  mind  and  those  trained  to  some  degree  of 
mental  discipline  and  capacity  for  submission,  such  as  soldiers  and 
artisans,  are  more  sensitive.  In  this  country  the  percentage  of  hyp- 
notizable  subjects  is  less  than  it  is  in  Europe.  Hysterical  and  in- 
sane persons  are  not  very  susceptible.  Those,  who  have  been  mes- 
merized once  are  more  easily  affected  afterward,  and  may  even  pass 
into  ihe  state  involuntarily. 

Methods. — There  are  two  ways  of  inducing  hypnotism,  the  fixa- 
tion method  and  the  suggestive  method.  The  former  and  older  plan, 
devised  by  Braid,  is  to  make  the  patient  fix  his  eyes  for  five  to  ten 
minutes  on  some  bright  object  at  a  distance  of  six  or  eight  inches 
from  the  eyes  and  a  little  above  the  horizontal  plane  of  vision.  A 
modification  of  this  is  the  fascination  method  of  buys,  by  which  the 
patienb  is  made  to  fix  his  eyes  on  revolving  mirrors. 

In  the  "suggestive  method"  devised  by  Liebault  and  Bernhenn 


586  DISEASES    OF   THE   NEEVOUS   SYSTEM. 

the  subject  is  placed  in  a  chair  in  front  of  the  operator.  The  oper- 
ator then  talks  to  the  subject  in  a  firm  and  confident  voice,  assuring 
him  that  he  will  go  to  sleep  in  a  short  time,  telling  him  to  make  no 
resistance,  that  his  sleeping  will  be  natural,  that  nothing  will  be 
done  to  worry  or  fatigue  him,  that  he  will  dream  pleasant  dreams, 
that  he  will  wake  up  feeling  better;  then  that  he  is  feeling  drowsy, 
his  eyes  are  heavy,  objects  look  confused,  the  lids  are  falling,  they 
are  closed — in  a  moment  more  the  patient  goes  off  to  sleep.  This 
requires  some  little  time — five  to  fifteen  minutes.  It  may  fail  the 
first  time  and  succeed  the  second. 

Hypnotic  states  may  be  self-induced  by  rigorously  fixing  the  at- 
tention upon  some  object.  The  ecstatic  states  of  the  saints  and  the 
nirvana  of  the  Buddhists  are  forms  of  hypnotism;  so  also  are  the 
trance  states  in  which  some  clairvoyants  and  spiritualistic  preachers 
place  themselves ;  this  same  curious  phenomenon  is  at  the  bottom  of 
the  so-called  "mind-healing"  science,  and  it  enters  into  rational 
therapeutics  and  orthodox  religion.  The  capacity  of  the  human 
mind  for  hypnotism  or  semihypnotic  states  is,  therefore,  a  most 
curious  and  important  fact. 

Symptoms  of  the  Major  Form. — The  person  who  has  been  hypno- 
tized at  first  sits  or  lies  quietly  in  the  position  he  has  assumed  during 
the  manipulations  of  the  operator.  No  notable  physiological  changes 
occur,  as,  for  example,  in  the  pulse,  respiration,  temperature,  pupils, 
skin,  etc.  Some  increase  in  the  cerebral  blood  supply,  however,  is 
said  to  be  present.  The  patient  will  now  respond  automatically  to  any 
outside  command  or  will  be  dominated  by  any  idea  which  is  suggested 
to  him.  He  will  talk,  or  walk,  or  run,  or  gesticulate,  assume  ex- 
pressions of  fright,  anger,  or  joy,  entirely  in  accordance  with  the 
command  given.  Apart  from  these  commands  he  is  entirely  dead 
to  the  outside  world.  He  hears,  sees,  smells,  tastes,  and  feels 
nothing.  He  can  be  burned,  cut,  or  injured  without  showing  any 
signs  of  feeling.  At  a  suggestion  he  may  be  made  cataleptic,  som- 
nambulic, or  paralytic.  This  state  is  termed  somnambulistic  trance. 
If  left  to  himself,  he  gradually  sinks  into  a  deep  sleep,  from  which 
he  can  with  difficulty  be  roused.  After  a  time,  rarely  more  than 
one  or  two  hours,  he  awakes  as  from  ordinary  slumber.  This  latter 
state  is  called  trance  coma,  or  lethargic  hypnotism.  The  attempts  of 
the  Charcot  school  to  divide  hypnotic  phenomena  into  three  forms, 
the  somnambulic,  cataleptic,  and  lethargic,  are  hardly  successful. 
Sensitive  subjects  can  be  thrown  at  once  into  lethargy,  catalepsy, 
or  somnambulic  states  at  the  command  of  the  operator. 

The  phenomena  of  hypnotism  depend  upon  the  wonderful  sen- 
sitiveness and  quickness  of  the  subject  in  responding  involuntarily, 


THE   DISORDERS   OF   SLEEP.  587 

with  all  his  nervous  energy,  to  outside  suggestion.  Dishonest  per- 
sons may  learn  the  latter  trick  and  thus  simulate  the  hypnotic  state. 
Travelling  mesmerizers  utilize  such  persons  largely;  hence  no  confi- 
dence can  be  placed  in  the  phenomena  exhibited  by  them. 

Minor  hypnotism  is  produced  by  the  "  suggestive  method"  of 
hypnotizing.  By  this  latter  plan  patients  are  thrown  into  various 
degrees  of  the  hypnotic  state  from  slight  drowsiness  to  lethargy, 
but  they  are  not  somnambulic,  and  do  not  become  cataleptic  or 
anaesthetic. 

Patients  naturally  come  out  of  the  mesmeric  state  through  the 
channel  of  deep  sleep  or  lethargy.  Ordinarily  they  are  dehyp- 
notized  by  word  of  command,  or  by  a  pass  of  the  hand,  or  any 
impression  which  the  patient  expects  to  be  used  for  the  purpose. 

Hypnotized  persons  have  been  observed  to  have  a  diminution  in 
the  spinal  reflexes  and  a  muscular  hyperexcitability.  They  some- 
times show  a  most  extraordinary  exaltation  of  visual,  auditory,  or 
other  special  sense. 

Pathology. — The  underlying  changes  of  the  hypnotic  condition 
are  unknown  and  will  probably  long  remain  so.  Hypnotism  is  no 
doubt  associated  with  changes  in  the  vascularity  of  different  parts 
of  the  brain  and  with  rapid  breaking  down  of  nerve  tissue.  Ani- 
mals constantly  subjected  to  hypnotic  influence  become  demented 
(Harting,  Milne-Edwards).  The  state  of  major  hypnotism  is  prob- 
ably pathological.  It  is  a  neurosis.  Minor  hypnotic  states  are 
but  slightly  removed  from  the  normal,  and  their  production  is  not 
injurious. 

Diagnosis. — As  hypnotic  states  may  be  imitated  and  as  injuries 
or  crimes  may  be  done  in  this  state,  it  is  very  important  to  be  able 
accurately  to  distinguish  it.  Since  the  phenomena  are  all  subjective, 
this  is  very  difficult.  The  methods  of  value  are  these:  1.  Careful 
examination  of  the  general  phenomena  by  experts  while  the  sub- 
ject is  in  the  alleged  hypnotic  state.  2,  Testing  the  muscular  hyper- 
excitability by  percussing  motor  points.  3.  Tests  of  alleged  anaes- 
thesia by  sudden  burning,  or  pinching,  or  injuring  the  subject.  4. 
Tests  of  the  tetanic  muscular  rigidity  by  the  revolving  tambour. 
In  the  hypnotic  state  the  hand  may  be  extended  and  held  with  per- 
fect steadiness,  while  in  conscious  states  a  tremor  soon  appears.  5. 
Tests  with  glasses  and  other  apparatus  may  be  made  to  determine 
alleged  anaesthesiae  of  the  special  senses. 

Therapeutics. — The  practice  of  using  major  hypnotization  is  in- 
jurious, tending  to  exhaust  the  nervous  force  and  weaken  the  will. 
It  should  be  done  only  with  the  greatest  care.  Its  utility  in  thera- 
peutics I  greatly  doubt.     It  may  relieve  symptoms  in  the  hysterical 


588  DISEASES   OF    THE    NERVOUS    SYSTEM. 

for  a  time,  but  it  cannot  be  of  permanent  benefit  and  is  likely  to 
lead  to  actual  harm. 

The  induction  of  minor  hypnotic  states  by  suggestion  is  not 
harmful  if  carefully  and  moderately  employed.  Its  practical  re- 
sults, however,  are  not  great,  and  the  method  is  tedious,  uncertain, 
and  sometimes  ridiculous.  It  has  its  value  in  pedagogy,  among 
children,  in  neurasthenia  and  in  morbid  habits.  The  general  popu- 
larization of  hypnotism  by  means  of  mind  cures,  Christian  science, 
etc.,  accomplishes  its  results  at  the  expense  of  mental  demoraliza- 
tion; and  faith-healing  institutes  are  pernicious  elements  in  society. 

Morbid  Drowsiness. — This  is  a  very  common  symptom,  which 
may  be  due  to  any  one  of  the  following  causes:  1.  Old  age,  when 
there  is  a  weakened  heart  or  diseased  arteries,  with  cerebral  mal- 
nutrition. 2.  The  diseased  vascular  conditions  which  precede  cere- 
bral hemorrhage.  3.  The  cerebral  malnutrition  occurring  before 
or  during  certain  forms  of  insanity.  4.  Various  toxaemia?,  e.g., 
malarial,  ursemic,  cholaeniic,  and  syphilitic.  5.  Dyspepsia  and 
gastric  repletion.  6.  Diabetes.  7.  Obesity.  8.  Insolation.  9. 
Cerebral  anaemia.  10.  Exhausting  diseases.  11.  Concussion  of 
the  brain.     12.  Climatic  conditions,  cold,  etc. 

A  very  common  cause  of  drowsiness  is  dyspepsia  attended  by 
some  torpidity  of  the  liver,  the  condition  popularly  known  as  "  bil- 
iousness." Another  frequent  cause  is  malarial  infection,  which 
perhaps  acts  indirectly  by  impairing  the  functional  activity  of  the 
liver.  Drowsiness  from  these  causes  oftenest  comes  on  in  the  after- 
noon. Anaemia  is  attended  by  drowsiness  during  the  day,  while 
there  is  often  insomnia  at  night.  Syphilis  is  more  likely  to  cause 
insomnia,  but  in  its  third  stage  somnolent  conditions  may  be  pro- 
duced which  are  of  serious  significance.  Drowsiness  occurs  from 
the  effects  of  severe  cold.  It  sometimes  develops  when  persons 
change  their  surroundings,  especially  on  going  to  the  seashore,  for 
low  levels  and  a  high  degree  of  atmospheric  pressure  seem  to  pro- 
mote sleep.  The  drowsy  state  that  sometimes  follows  concussion 
of  the  brain  is  a  familiar  phenomenon.  Some  persons,  no  doubt, 
acquire  the  habit  of  drowsiness.  At  first  the  trouble  may  have 
been  induced  by  indigestion,  "biliousness,"  or  malarial  infection, 
but  it  persists  after  the  cause  is  removed.  Such  persons  can  hardly 
sit  through  a  lecture,  a  church  service,  or  any  exercise  requiring 
quiet  and  attention.  As  the  morbid  drowsiness  here  described  is 
only  symptomatic,  its  treatment  need  not  be  discussed.  Such  rem- 
edies as  coca,  coffee,  tea,  atropine,  glonoin,  do  not  produce  results 
equal  to  expectations. 

Morbidly  I)e^jj  Sleep. — Certain  persons,  when  they  sleep,  pass 


THE    DISORDERS    OF    SLEEP.  589 

into  an  almost  lethargic  slumber.  Persons  who  sleep  in  this  way 
often  sleep  a  longer  time  than  normal.  They  are  awakened  with 
difficulty,  and  then  suffer  with  headache  or  disagreeable  sensations 
throughout  the  day.  The  symptom  may  be  a  prodroma  of  insanity. 
Instances  in  which  persons  retire  at  the  usual  hour,  but  can  with 
great  difficulty  be  roused  in  time  for  the  ordinary  duties  of  the  day, 
are  not  rare.  Some  of  these  are  illustrations  of  the  vice  of  indo- 
lence, but  in  other  cases  there  is  an  absolute  need  of  nine,  ten,  or 
even  fourteen  hours  of  sleep. 

This  disorder  of  sleep  is  most  liable  to  occur  in  the  young  and 
in  those  of  nervous  temperament.  It  often  seems  to  be  a  congeni- 
tal condition,  for  which  nothing  can  be  done.  In  other  cases  it 
results  from  overfeeding  and  indolent  habits.  Treatment  is  much 
the  same  as  that  indicated  for  sleep-drunkenness  and  somnam- 
bulism. 

Paroxysmal  Sleep,  Xu  rcohpsy,  Sleep  Epilepsy. — It  sometimes 
happens  that  persons  suffer  from  sudden  attacks  of  unconquerable 
drowsiness;  they  fall  off  into  slumber  despite  every  effort  of  the 
will.  These  are  more  than  drowy  sensations,  for  sleep,  or  a  state 
resembling  it,  cannot  be  kept  off.  Some  of  these  cases  are  of  a 
purely  nervous  character,  i.e.,  the  trouble  is  not  due  to  a  humoral 
poison  or  to  organic  disease,  but  to  a  paroxysmal  change  in  the  ner- 
vous centres  of  a  vascular  or  chemical  character,  causing  sleep.  It 
may  be  that  the  patient  is  epileptic  and  the  sleep  seizure  takes  the 
place  of  the  ordinary  epileptic  spasms. 

Cases  of  epileptic  sleep,  or  narcolepsy,  and  allied  forms  are  not 
of  frequent  occurrence.  Females  are  rather  more  often  affected 
than  males,  and  the  susceptible  age  is  from  fifteen  to  forty.  The 
disorder  is  brought  on  sometimes  by  fright,  overstrain,  and  humoral 
poisons  acting  on  a  predisposed  nervous  system. 

The  course  is  chronic  and  relief  is  not  always  obtained.  It 
should  be  remembered  that  syphilis,  malaria,  or  anaemia,  and  indi- 
gestion may  be  elements  in  the  trouble  which  are  important,  if  not 
fundamental.  Bromides  in  small  doses  are  often  useful  factors  in 
treatment.  Change  of  occupation,  of  mode  of  life,  or  of  climate 
may  be  essential  to  a  cure. 

Catalepsy,  Trance,  Lethargy. — Most  of  the  so-called  cases  of 
prolonged  sleep,  lasting  for  days  or  weeks,  are  cases  of  spontane- 
ously developed  mesmeric  sleep  in  hysterical  women,  or  cases  of  in- 
cipent  insanity  (katatonia  or  stuporous  melancholia).  The  phe- 
nomena in  these  cases  may  take  the  form  of  catalepsy,  with  waxy 
rigidity  of  the  limbs,  or  lethargy.  In  cataleptic,  states  the  limbs 
may  be  placed  in  various  positions  and  will  remain  there  for  several 


590 


DISEASES   OF   THE    NERVOUS    SYSTEM. 


minutes  (Fig.  242).  In  lethargy  or  trance  states  the  patient  may 
be  plunged  into  a  deep  and  prolonged  unconsciousness,  lasting  from 
one  day  to  several  years.  These  are  the  "  sleeping  girls"  of  the 
newspapers.  Others  are  persons  of  a  too  ready  susceptibility  to 
mesmeric  suggestion,  who  get  into  a  morbid  habit  of  going  into 
mesmeric  sleep  spontaneously.  In  these  states  there  may  be  a  low- 
ering of  bodily  temperature,  slowing  of  respiratory  and  heart  ac- 
tion, and  excessive  sluggishness  of  the  action  of  the  bowels.  The 
patients  can  hear  and  may  respond  to  suggestions,  but  they  are  ap- 
parently insensible  to  painful  impressions  and  do  not  appear  to  smell, 
taste,  hear,  or  see.     The  eyes  are  closed  and  turned  upward,  and  the 


Fig.  242.  —A  Case  of  Catalepsy. 


pupils  contracted  as  in  normal  sleep.  Many  Variations,  however, 
occur  in  the  physiological  phenomena  of  these  states. 

The  duration  of  the  attacks  of  trance  lethargy  is  from  a  few 
hours  to  ten  years.  Ordinarily,  however,  profound  trance  sleep 
lasts  not  more  than  a  few  days,  while  those  cases  in  which  the  sleep 
is  from  mesmeric  suggestion  lasts  but  a  few  hours. 

The  katatonic  patients  after  a  few  weeks  or  months  gradually 
awake,  become  excited,  and  then  pass  into  a  condition  of  dementia 
or  into  catalepsy  again. 

Mokbid  Sleep  fkom  Organic  Disease. — Prolonged  and  ex- 
cessive sleep  occurs  as  the  result  of  syphilis  of  the  brain,  brain  tu- 
mors, and  the  degenerative  changes  in  old  age  and  insanity.  Mor- 
bid somnolence  and  stupor  are  not  very  frequent  in  cerebral  syphilis, 
but  are  quite  characteristic.  The  patient  in  some  cases  lies  or  sits  all 
day  in  a  semisoporous  state ;  in  other  cases  he  walks  about,  but  con- 
tinually sleeps  at  his  task.  This  state  of  partial  sleep  may  pass  off 
or  end  in  complete  stupor  (Wood).     It  does  not  necessarily  signify  a 


THE    DISORDERS    OF   SLEEP.  59  L 

serious  issue,  even  though  it  last  for  weeks.  Somnolence  or  sleep 
is  a  rare  symptom  in  cases  of  cerebral  tumors  other  than  syphilitic. 
Conditions  of  drowsiness  or  stupor  have  been  noted  especially  in 
tumors  of  the  basal  ganglia  and  third  ventricle. 

Organic  diseases  of  the  brain  tend  to  produce  conditions  of  men- 
tal weakness,  hebetude,  or  comatose  states,  rather  than  anything 
allied  to  sleep. 

The  Sleeping  -  Sickness,  Sleeping  -  Dropsy,  Maladie  du 
Sommell. — This  is  a  peculiar  disorder,  apparently  infectious  in 
character,  which  occurs  among  the  negroes  of  the  western  coast  of 
Africa.  ■  The  disease  has  been  transported  to  other  regions,  but  is 
endemic  only  in  Africa.  It  begins  gradually  with  some  headache 
and  malaise.  Soon  there  is  felt  a  drowsiness  after  meals.  This 
increases  until  the  patient  lies  for  nearly  the  whole  time  in  a  stupor. 
When  awake  he  is  dull  and  apathetic.  There  seems  to  be  no  fever, 
and  the  temperature  may  even  be  subnormal ;  the  pulse,  too,  is  not 
rapid;  the  skin  is  dry,  the  tongue  moist  but  coated,  the  bowels  are 
regular.  The  eyes  become  congested  and  prominent.  The  cervical 
glands  are  enlarged.  The  disease  ends  in  coma  and  finally  death. 
Recovery  rarely  occurs.  Sometimes  the  course  of  the  disease  is 
more  violent,  and  toward  the  end  there  are  epileptic  convulsions 
and  muscular  tremors.  Autopsies  have  revealed  no  definite  patho- 
logical changes. 

Accidents  of  Sleep. — Owing  to  the  fact  that  sleep  is  a  resting 
state  of  the  organism,  and  that  many  of  its  functions  are  lowered, 
or  their  cerebral  control  lessened,  peculiar  crises,  or  physiological 
and  pathological  disturbances  of  nervous  equilibrium,  occur.  At- 
tacks of  gout,  of  asthma,  and  of  pulmonary  hemorrhage  are  most 
liable  to  occur  during  the  early  morning  hours.  Deaths  and  sui- 
cides occur  oftener  in  the  forenoon,  but  births  oftener  at  night. 
Epileptic  and  eclamptic  attacks  occur  with  much  frequency  at  night. 
Involuntary  emissions  of  spermatic  fluid,  orgasmic  crises,  ami  in- 
continence of  urine  are  among  the  pathological  incidents  of  sleep. 

Disorders  of  the  Pe^hdoemitittm. — Sudden  attacks  of  start- 
ing of  the  whole  body,  shock-like  in  character,  accompanied  by 
peculiar  feeling  in  the  head  or  occiput,  not  infrequently  attack 
persons  as  they  are  dropping  off  to  sleep.  They  are  of  slight  sig- 
nificance. 


CHAPTER  XXX. 

CRANIOCEREBRAL  TOPOGRAPHY. 

The  object  of  cranio-cerebrai  topography  is  to  map  out  upon  the 
scalp  the  underlying  fissures,  convolutions,  and  other  parts  of  the 
brain.  As  this  is  for  purposes  of  surgical  operations,  the  mapping 
is  done  upon  the  shaved  aseptic  scalp  with  a  soft  anilin  pencil 
dipped  in  strong  carbolic  solution  (1  to  4),  or  with  a  brush  and  car- 
bolized  tincture  of  iodine.  The  only  instruments  needed  are  a  steel 
tape  measure  and  an  instrument  of  nickel-plated  soft  iron.  This 
consists  of  a  flat  strip  25  cm.  long  and  1  cm.  wide.  From  its  middle 
there  branches  a  second  strip  10  cm.  long  making  an  angle  of  67° 
with  the  longer  strip.*  Practically,  the  principal  points  to  be  de- 
termined are  the  position  of  the  longitudinal,  Rolandic,  Sylvian,  and 
parieto-occipital  fissures  and  the  lower  outline  of  the  brain. 

The  measurements  are  based  chiefly  upon  the  known  relations 
of  certain  landmarks  on  the  skull  to  the  parts  beneath.  These 
landmarks  are  the  glabella,  bregma,  lambda,  stephanion,  asterion, 
and  pterion,  which  are  points  at  the  junction  of  the  various  sutures 
with  each  other  and  with  certain  ridges  or  protuberances.  Their 
position  is  shown  in  the  cut  (Pig.  240)  except  that  of  the  glabella 
or  prominence  just  above  the  nasofrontal  suture.  The  inion  is 
identical  with  the  occipital  protuberance. 

The  following  rules  are  based  upon  the  observations  of  Heftier, 
Thane,  Reid,  Horsley,  Eraser,  and  myself : 

I.  The  longitudinal  fissure.  This  corresponds  with  the  naso- 
occiptal  arc. 

II.  The  fissure  of  Rolando.  Measure  the  distance  from  the 
glabella  to  the  inion;  find  55.7  per  cent  of  this  distance,  and  the 
figures  obtained  will  indicate  the  distance  of  the  upper  end  of 
the  fissure  of  Rolando  from  the  glabella.  It  should  be  about  48 
mm.  behind  the  bregma  in  male  adults,  45  mm.  in  women,  30  to  42 
mm.  in  infants  and  young  children  respectively. 

The  fissure  runs  downward  and  forward  for  a  distance  of  about 
10  cm.  measured  on  the  scalp,  the  real  length  being  about  8.5  cm. 

*  Special  instruments  called  cyrtometers  have  been  devised  by  Wilson  and 
Horsley,  but  are  not  necessary. 


CRANIOCEREBRAL  TOPOGRAPHY. 


593 


The  fissure  makes  an  angle  of  about  67°  with  the  anterior  part  of 
the  longitudinal  fissure.  This  direction  is  determined  by  the  in- 
strument above  described  or  by  the  cyrtometer.  The  lower  third 
of  it  is  more  vertical,  and  the  lower  end  is  25  to  30  mm.  behind  the 
coronal  suture.  A  line  from  the  stephanion  to  the  upper  part  of 
the  asterion  should  about  pass  through  it.  The  fissure  is  shorter 
in  children. 

III.  The  fissure  of  Sylvius  runs  nearly  horizontally,  and  lies 
either  under  or  a  little  above  the  uppermost  part  of  the  parieto- 
squamous  suture.  This  suture,  the  external  orbital  process,  and  the 
parietal  eminence  are  the  guiding  landmarks  by  help  of  which  the 


Fig.  243. —Showing  the  Position  of  the  Bony  Points  on  the  Cranium,  the 
Sutures,  and  the  Principal  Underlying  Fissures,  also  the  Basal  Outline  or  the 
Brain. 

surgeon  can  often  operate  without  marking  down  lines  on  the  scalp. 
In  children  the  fissure  is  sometimes  higher  and  more  oblique. 

To  outline  it,  draw  a  vertical  line  from  the  stephanion  to  the 
middle  of  the  zygoma.  Draw  a  horizontal  line  from  the  external 
angular  process  to  the  highest  part  of  the  squamous  suture ;  con- 
tinue this  back,  gradually  curving  it  up  till  it  reaches  the  parietal 
eminence.  The  junction  of  the  two- lines  will  beat  the  beginning 
of  the  fissure  of  Sylvius.  The  vertical  line  indicates  nearly  the  po- 
sition of  the  ascending  or  vertical  branch  of  the  fissure,  which  is, 
however,  directed  a  little  more  forward,  and  is  about  2.5  cm.  (1 
inch)  in  length.  The  posterior  part  of  the  line  indicates  the  posi- 
tion of  the  posterior  branch  of  the  fissure.  Reid's  method  of  find- 
ing the  fissure  of  Sylvius  is  to  "  draw  a  line  from  a  point  1  [■  inches 
38 


594  DISEASES   OF   THE   NERVOUS   SI  STEM. 

behind  the  external  angular  process  to  a  point  f  inch  below  the 
parietal  eminence.  The  ascending  branch  starts  from  a  point  f  inch 
back  from  the  anterior  end  of  this  line,  and  2  inches  (5  cm.)  back 
of  the  external  angular  process." 

IV.  To  outline  the  parieto-occipital  fissure,  find  the  lambda, 
mark  a  point  3  mm.  anterior  to  it,  draw  a  line  through  this  at  right 
angles  to  the  longitudinal  fissure,  extending  about  2.5  cm.  (1  inch) 
on  each  side  of  the  median  line.  This  marks  the  position  of  the 
fissure.  If  the  lambda  cannot  be  felt,  its  position  may  be  found  by 
measuring  the  naso-occipital  arc  and  taking  22.8  per  cent  of  it. 
This  indicates  the  distance  of  the  lambda  from  the  inion  or  external 
occipital  protuberance.  The  average  distance  in  male  adults  is  7.42 
cm.  (2^  inches).  It  is  greater  in  women  than  in  men  by  a  little 
over  a  millimetre. 

V.  To  outline  the  frontal  lobes :  The  anterior  end  of  the  frontal 
lobes  reaches  to  a  point  determined  by  the  thickness  of  the  frontal 
bone.  This  ranges  from  2  to  8  or  more  mm.  (TV  to  ^  inch).  The 
floor  of  the  anterior  fossa  reaches  in  front  to  a  level  a  little  above 
the  supra-orbital  margin  (16  mm.,  -|  inch — Heftier).  It  slopes 
down  and  backward,  its  posterior  limit  being  indicated  by  the 
lower  end  of  the  coronal  suture. 

VI.  To  outline  the  temporal  lobe  and  the  lower  border  of  the 
cerebrum :  The  temporal  lobe  is  limited  above  by  the  fissure  of  Syl- 
vius, below  by  the  contour  line  of  the  lower  border  of  the  cerebrum. 
This  latter  corresponds  to  a  line  drawn  from  a  point  slightly  (about 
12  mm.)  above  the  zygoma  and  the  external  auditory  meatus  to  the 
asterion,  and  continued  on  along  the  superior  occipital  curve  to  the 
inion.  The  anterior  border  of  the  lobe  corresponds  to  the  posterior 
border  of  the  orbital  process  of  the  malar  bone. 

The  temporal  lobe  is  about  4  cm.  (1^  inches)  wide  at  the  external 
auditory  meatus.  A  trephine,  as  Bergmann  states,  placed  half  an 
inch  above  the  meatus  would  enter  the  lower  part  of  the  lobe.  The 
middle  of  the  lobe  is  in  a  vertical  line  from  the  posterior  border  of 
the  mastoid  process.  A  line  from  the  upper  end  of  the  fissure  of 
Rolando  to  the  point  of  the  process  would  pass  through  this  impor- 
tant sensory  area  (Fig.  243;  see  also  p.  411')- 

VII.  To  find  the  position  of  the  central  ganglia,  viz.,  corpus 
striatum  and  optic  thalamus,  draw  a  line  from  the  upper  end  of  the 
fissure  of  Rolando  to  the  asterion,  practically  a  vertical  line.  This 
limits  the  optic  thalamus  posteriorly.  A  vertical  line  parallel  to 
\he  first,  a  little  in  front  of  the  beginning  of  the  fissure  of  Sylvius, 

limits  the  corpus  striatum  anteriorly.     A  horizontal  plane  45  mm. 

(L£  inches)  below  the  surface  of  the  scalp  at  the  bregma  limits 


CRAXIO-CEREBRAL   TOPOGRAPHY. 


595 


the  ganglia  superiorly.     The  ganglia  lie  about  35  inm.  (1£  inches) 
below  the  superior  convex  surface  of  the  brain  (Fere). 

VIII.  To  reach  the  lateral  ventricles :  A  number  of  routes  may 
be  taken.  The  lateral  is  recommended  by  Keen.  Mark  a  point 
1 1:  inches  behind  the  external  auditory  meatus  and  1  \  inches 
above  a  base  line  made  by  drawing  a  line  through  the  lower  border 
of  the  orbit  and  the  external  auditory  meatus.  Trephine  at  this 
point  and  plunge  the  director  into  the  brain  in  the  direction  of  a 


Fiu.  244.— showing  the  relative  Position  of  tee  Fissures  axd  Cortical  Centres  op 

the  Brain. 


point  2\  to  3  inches  vertically  above  the  opposite  external  meatus. 
The  ventricle  lies  at  a  depth  of  2  to  2}  inches  (5  to  5.7  cm.). 

Mr.  Alec  Fraser  has  devised  a  way  of  mapping  out  the  fissures 
by  means  of  a  series  of  composite  photographs,  so  taken  as  to  show 
tli  )  relation  of  the  underlying  parts  to  certain  tapes  tacked  upon 
the  skull.     One  of  his  figures  is  reproduced  here  (Plate  III.). 

In  applying  this  method  the  surgeon  tacks  the  tapes  on  the 
shaved  scalp.  Then  looking  at  the  diagram,  he  finds  where  the 
point  in  the  brain  is  that  he  wishes  to  reach  and  notes  its  relation 
to  the  median  lateral  or  circumferential  tapes.  Then  as  the  circum- 
ference of  the  illustrated  head  is  to  the  circumference  of  the  living 
one,  so  is  the  position  of  the  area  on  the  tapes  in  the  illustrated 


590  DISEASES   OF   THE   NERVOUS   SYSTEM. 

head  to  the  desired  position  of  the  same  area  in  the  living  one. 
The  illustration  is  a  composite  of  several  adult  heads  varying  in 
circumference  from  20£  to  23^-  inches. 

The  tapes  are  divided  into  inches  and  half -inches.  The  primary 
tape  is  the  circumferential  passing  horizontally  round  the  vault  of 
the  head  (on  the  shaven  scalp)  from  the  root  of  the  nose  (glabella) 
to  the  maximum  occipital  point,  which  is  about  one  inch  above  the 
inion.  The  tape  which  thus  entirely  surrounds  the  head  is  divided 
into  four  equal  parts.  The  points  where  the  division  is  made  are  at 
the  anterior  and  posterior  poles  and  midway  on  each  lateral  half  of  the 
tape.  From  these  lateral  mid-points  a  tape  is  run  vertically  over 
the  top  of  the  head,  and  other  tapes  are  run  anteriorly  and  poste- 
riorly half-way  between  the  point  where  the  transverse  tape  crosses 
the  sagittal  suture  and  the  anterior  and  posterior  poles.  Another 
longitudinal  tape  is  run  from  the  anterior  to  the  posterior  pole  half- 
way between  the  sagittal  suture  and  the  circumferential  tape. 


APPENDIX. 
ON   NEUROLOGICAL   THERAPEUTICS. 

It  has  seemed  best  to  describe,  in  a  separate  chapter,  some  of 
the  technical  details  of  the  treatment  of  nervous  diseases. 

HvDKOTIIEKAPY. 

The  apparatus  needed  for  applying  water  in  therapeutics  con- 
sists of  a  room  at  least  sixteen  by  twenty  feet,  well  ventilated,  with 
waterproof  floor  and  walls.  The  floor  must  be  made  so  that  it  will 
drain  away  the  water  flowing  upon  it.  The  room  should  contain  a 
stationary  bathtub,  a  shower  or  rain  bath,  an  apparatus  for  giving 
hot  ami  cold  douches  at  various  pressures,  a  hot  box  in  which  a 
patient  can  take  a  hot  hath  with  the  head  exposed,  a  few  foot  baths, 
ice  hags  and  ice  caps.  The  most  important  point  in  detail  is  the 
douche  apparatus,  which  should  be  supplied  with  all  the  improve- 
ments for  regulating  the  heat,  pressure,  and  impact  of  the  stream. 
The  stationary  bathtub  should  he  of  the  largest  possible  size,  rather 
shallow,  ami  placed  low  down  so  that  patients  can  move  their  limbs 
easily  and  get  exercise  while  in  it.  Among  the  accessories  may  be 
aporium,"  devised  by  I>r.  Percy  Wilde  for  local  application 
of    heat    or   cold.       It    consists   of   a    double    copper   cover,   made    in 

sizes,  one  suitable  for  a  single  limb,  the  other  for  both  ex- 
tremities, the  abdomen,  or  thorax.  Boiling  water  is  poured  into 
the  upper  part  (at  Ti),  and  permitted  to  escape  by  two  outlet  pipes 
(i)  at  the  bottom.  This  apparatus  has  beer  greatly  elaborated  re- 
cently, so  that  temperatures  of  over200£  F.  are  reached  and  applied 
locally. 

While  all  the  foregoing  things  are  needed  in  an  institution  and 
should  be  placed  in  every  hospital  and  asylum,  most  of  the  hydro- 
therapeutic  procedures  can  he  carried  out  fairly  well  witli  a  stationary 
tub  and  a  shower  above  it.  A  cheap  hot  box  with  a  hole  iu  the  top 
and  a  lamp  for  heating  below  can  be  easily  added  if  needed.  The 
common  forms  of  hydrotherapy  prescribed  by  myself  are  the  hot 


598  DISEASES    OF   THE    NERVOUS    SYSTEM. 

box  and  Charcot  or  Scottish  douches,  the  cold  sitz  bath,  the  drip 
sheet,  and  wet  pack. 

Special  Applications  of  Hydrotherapy — Epilepsy. — Most 
patients  should  be  made  to  take  cold  showers  or  sponge  baths  with  a 
vigorous  rub-off  daily  in  the  morning.  Once  a  week  they  should  take 
a  hot  bath.  A  cold  plunge  into  a  tub  full  of  wat  r  is  a  good  sub- 
stitute for  the  shower.  Persons  who  have  neither  shower  nor  tub 
should  get  a  foot  tub  and  a  large  sponge.  Standing  in  the  tub  with 
a  basin  of  cold  water  before  them,  they  should  fill  the  sponge  and 
let  the  water  trickle  over  the  head,  back,  and  body  generally. 
This  is  done  for  two  or  three  minutes,  then  the  patient  rubs 
himself  down.  The  foot  tub  may  have  little  warm  water  in  it  at 
first. 

With  delicate  persons  hydrotherapeutic  treatment  must  be  begun 
carefully.  The  first  applications  should  be  dry,  warm  flannel  packs, 
then  wet  packs  gradually  made  cold.  Finally,  cold  drip  sheets, 
showers,  plunges,  and  rubbing  may  be  used. 

A  good  method  for  a  fairly  robust  person  is  that  originally  de- 
scribed by  Fleury.  This  consists  in  giving  simultaneously  the  rain 
shower  and  the  jet.  The  patient  standing  in  the  shower  receives  a 
jet  of  water  on  the  posterioi  surface  of  the  body  for  fifteen  seconds ; 
then  the  jet  alone  for  fifteen  seconds;  finally  the  jet  alone  on  the 
anterior  surface  of  the  body  for  thirty  seconds. 

In  neurasthenia  of  adult  life  in  men  the  patient  should  take  the 
cold  shower  or  plunge  daily.  In  addition  to  this  or  in  place  of  it, 
if  needed,  I  strongly  advise  the  Scottish  douche  thrice  weekly  or 
oftener.  This  may  be  preceded  by  a  short  hot  bath.  In  neuras- 
thenia of  adolescence  the  same  treatment  is  often  indicated,  but  it 
must  be  applied  more  carefully,  as  many  patients  do  not  react  well 
at  first.  They  may  require  wet  packs  and  lukewarm  baths  as  seda- 
tives for  a  time.  Nervous  women  almost  always  do  better  with 
a  preliminary  course  of  dry  and  wet  packs,  followed  later  by  show- 
ers and  douches.  Thus  I  prescribe  first  a  hot  flannel  pack  for  one 
half  to  one  hour  (see  p.  64) ;  next  day  a  wet  pack,  using  a  hot 
sheet ;  next  day  a  cooler  sheet,  until  in  one  or  two  weeks  the  pa- 
tient takes  a  cold  wet  pack  thrice  weekly.  If  this,  however,  does 
not  lessen  irritability  and  quiet  the  patient,  I  prescribe  a  hot-air 
bath  followed  by  a  shower  or  douche. 

Insomnia. — The  lukewarm  bath  at  a  temperature  of  90°  to  96° 
F.  is  often  efficacious.  It  should  be  taken  at  night  before  retiring, 
and  should  last  from  fifteen  minutes  to  three-quarters  of  an  hour. 
A  cold  cloth  may  be  laid  on  the  patient's  head.  A  simpler  method 
of  inducing  sleep  is  to  make  the  patient  thrust  the  feet  into  a  basin 
of  cold  water,  40°  F.  to  50°  F.      The  legs  are  sponged  up  to  the 


NEUROLOGICAL   THERAPEUTICS.  599 

knees.  This  is  done  for  fifteen  or  thirty  seconds,  then  the  feet  are 
taken  out  and  briskly  rubbed.  The  most  efficacious  measure  often 
is  the  hot  wet  pack.  The  pack  is  taken  like  a  cold  pack,  only  the 
sheet  is  ■wrung  out  in  hot  water.  The  patient  lies  upon  this,  and 
the  sheet  and  then  the  blanket  are  folded  about  him.  The  duration 
is  an  hour  or  all  night.  In  the  rest-cure  treatment  a  drip  sheet  is 
used  (see  Partial  Rest-Cure,  p.  605). 

Headache  of  a  congestive  character  is  helped  by  cold  foot  baths 
or  cold  douches  to  the  feet;  or  a  bath  at  60°  F.,  which  should  last 
ten  or  twenty  minutes  and  be  accompanied  by  friction  to  the  feet  and 
legs.  In  anaemic  headaches  the  head  should  be  wrapped  in  thin 
linen  bandages  wrung  out  in  very  cold  water  and  covered  with  a 
few  layers  of  flannel.  After  they  are  removed  the  head  is  to  be 
rubbed  dry  and  covered  with  a  dry  cloth. 

In  hysteria  much  the  same  kind  of  treatment  is  indicated  as  in 
neurasthenia.  "When  there  is  much  excitement  the  wet  packs  are 
indicated.  In  most  of  the  major  forms  a  half-bath  at  60°  with  cold 
affusions,  or  the  shower,  with  Charcot  or  Scottish  douche,  should  be 
given.     The  ordinary  treatment  at  the  Montefiore  Home  consists  of: 

Cold  affusions  while  standing  in  warm  water,  or  a  hot-air  bath 
followed  by  rain  bath  for  thirty  seconds  at  85°,  daily  reduced  until 
60°  is  reached,  this  to  be  followed  by  a  spray  douche  for  five  seconds 
at  G5°  or  jet  douche  for  three  seconds  at  65°  to  55°.  The  douche 
is  reduced  gradually  to  50°  or  less,  increasing  the  pressure  from  two 
pounds  to  thirty  (Baruch). 

When  there  is  spinal  irritation  the  filiform  douche  may  be  used 
as  a  counter-irritant,  or  the  shower  at  65°  to  85°. 

In  locomotor  ataxia  different  patients  get  relief  from  different 
forms  of  treatment.  The  very  painful  and  hypersesthetic  cases  are 
not  in  my  experience  much  helped  by  hydrotherapy.  One  may  try, 
however,  lukewarm  baths,  85°  F.  to  95°  F.,  for  ten  to  twenty 
minutes,  with  or  without  pine-needle  extract.  For  leg  pains,  hot- 
air  baths  to  the  legs  alone,  followed  by  affusions  at  G0°  to  70°,  are 
recommended.  The  extremities  may  also  be  wrapped  in  flannels 
wrung  out  in  hot  water  and  covered  with  dry  cloths.  Some  pa- 
tients are  greatly  refreshed  and  helped  by  cool  affusions,  70°  to  80°, 
poured  over  the  back  and  legs.  In  painful  cases,  relief  can  be  ob- 
tained sometimes  by  applying  the  Charcot  douche  at  a  very  high 
temperature  to  the  back.  The  temperature  at  first  is  90°  F.  This 
is  gradually  increased  to  about  160°  F.  The  duration  of  treatment 
should  be  only  about  one  minute. 

Spermatorrhoea. — Cold  sitz  baths  may  be  given  for  from  five  to 
twenty  minutes,  50°  to  70°,  daily  at  bedtime. 


600  DISEASES    OF   THE    NERVOUS    SYSTEM. 

Impotence. — Brief  cold  sitz  baths,  daily,  at  56°  to  64°,  for  from 
one  to  five  minutes.  The  psychrophore,  i.e.,  application  to  the 
prostate  of  cold  by  a  rubber  condom  or  bladder  secured  over  a 
rectal  irrigator  an  double  entrant,  is  sometimes  helpful. 

Incontinence  of  Urine. —  In  paresis  of  sphincter  or  detrusor,  brief 
cold  sitz  baths,  daily,  56°  to  64°,  one  to  five  minutes,  are  indicated; 
also  cold  rain  baths  (50°  to  60°)  and  douches  as  general  tonics.  In 
spasmus  detrusorum  vesicae,  on  the  contrary,  prolonged  lukewarm 
sitz  baths  daily  for  thirty  to  sixty  minutes,  at  70°  to  90°,  should  be 
given. 

Electro-Thekapkuth  s. 

Sigh  ami  Low  Potential.  Currents — Currents  of  "  Tension7*  and 
"  Quantity." — The  current  of  the  faradic  battery  varies  in  quality 
in  accordance,  1,  with  the  length  and  number  of  turns  in  the  coil: 
2,  the  form  of  the  electrical  wave ;  3,  the  number  of  vibrations ;  and, 
4,  the  strength  of  the  battery. 

The  currents  from  short  coils  of  coarse  wire  have  a  lower  poten- 
tial and  slightly  more  voltage.  They  are  more  efficient  in  producing 
muscular  contractions  and  are  more  irritating  to  the  sensory  nerves. 
These  qualities  are  increased  with  slow  interruptions  of  three  or 
four  per  second.  When  muscular  contractions  and  mechanical  ex- 
ercise with  stimulation  are  desired  the  short  coils  (primary  or  sec- 
ondary) with  slow  interruptions  are  indicated.  The  current  from 
long  coils  has  a  higher  potential  and  less  voltage;  it  has  less  power 
in  contracting  muscles  and  a  different  effect  on  the  sensory  nerves. 
When  the  interruptions  are  very  rapid  and  the  coil  is  very  long,  the 
effect  on  the  sensory  nerves  seems  more  sedative,  perhaps  in  part 
because  of  a  change  in  the  form  of  the  electrical  waves. 

Instrument  makers  have  devised  instruments  with  long  coils 
(1,500  yards)  which  are  tapped  at  three  places,  so  that  with  one 
coil  it  is  possible  to  get  a  current  of  low  potential  (  or  "quantity  "  as 
it  has  been  called)  or  of  high  potential  i  or  "current  of  tension  "). 
The  vibrator  is  made  also  so  that  currents  of  extremely  rapid  inter- 
ruption can  be,  obtained.  These  instruments  are  expensive,  but 
are  of  special  use  to  the  neurologist  in  those  cases  in  which  he 
desires  to  apply  faradism  for  spasm  or  neuralgia.  They  are  said 
to  be  very  useful  in  gynaecological  work.  Dr.  Rockwell  has 
advocated  their  use  and  shown  their  value.  My  own  experience 
with  the  very  high  tension  long  coils  is  slight,  but  the  theory  on 
which  they  are  based  is  sound;  and  the  fact  of  their  peculiar  phys- 
ical properties  is  attested  by  Mr.  Kenelly. 

The  physiological  effect  of  a  current  depends,  as  I  have  stated, 
in  part  upon  the  character  of  the  wave  of  electrical  force.  If  this 
is  high  and  sharp,  the  stimulation  is  different  from  that  produced  by 


NEUROLOGICAL   THERAPEUTICS.  601 

a  wave  which  gradually  rises  to  its  height.  P' Arson  val  has  de- 
vised an  instrument  for  producing  these  blunt-topped  waves,  and 
at  the  same  time  reversing  the  current.  The  current  is  called  sinu- 
soidal and  is  produced  by  revolving  magnets,  and  the  machine  is 
expensive  and  complicated.  The  same  result,  I  am  told  by  Mr. 
Kenelly,  is  approximately  produced  by  the  faradic  machine  with 
long  coils  and  very  fine  interruptions  by  means  of  a  vibrating  band, 
as  described  above.  I  am  not  aware  of  any  special  therapeutic 
results  in  neurology  from  this  kind  of  current. 

VlBBATOBY    ThEBABEUTICS. 

Some  relief  of  pain  and  spasm  is  secured  by  mechanical  vibra- 
tions applied  generally  or  locally.  The  most  efficient  means  for 
this  purpose  is  a  vibrator  with  various  terminals,  which  is  run  by 
hand,  or  by  a  motor.  By  means  of  a  vibrating  metal  helmet  ap- 
plications can  be  made  to  the  head,  and  by  a  vibrating  chair  the 
whole  body  can  be  shaken.  This  produces  very  rapid  vibrations 
and  a  kind  of  benumbing  of  the  part.  The  art  of  applying  vibra- 
tion in  slower  oscillations  has  been  fully  developed  by  Zander  and 
is  carried  out  in  various  Zander  institutes,  of  Avhich  there  are  many 
in  Europe  and  two  in  Xew  York. 

PENSION. 

Suspension  by  the  head  and  arms  in  a  Sayre  apparatus  is  oc- 
casionally used.  The  patient  is  raised  from  the  ground  for  from  one 
to  three  minutes,  daily  or  triweekly.  Or  while  seated  in  a  chair  he 
is  partly  lifted  from  his  seat  for  from  five  to  fifteen  minutes.  This 
measure  will  sometimes  give  relief  in  locomotor  ataxia,  paralysis 
agitans,  sciatica,  lumbago,  and  chronic  myelitis.  Its  application 
requires  care.  According  to  Bogroff  it  produces  a  slight  stretching 
of  the  cord  and  membranes  and  slight  meningeal  congestion. 

Om.AMc    EXTBACTB. 

The  Thyroid  Gland.-  -This  is  used  successfully  in  the  treatment 
of  myxcedema,    certain    forms   of  insanity,   and  in   some   casi 
ubesity.     It  does  no  good   in  other  diseases  >(,  far  as  known.      It  is 
given  usually  in  the  form  of  tablets  of  the  dried  gland  in  doses  of 
gr.  v.,  gradually  increased  in  some  cases  to  ;_,rr.  lx.  daily. 

Orchitic  Extract.  There  is  some  evidence  that  the  extract,  of 
testicle  has  a  tonic  effect  on  the  nerve  cent  1 1 

The  value  of  other  organic  extracts  in  nervous  diseases  is  still 
undetermined. 


602  DISEASES   OF   THE    NERVOUS    SYSTEM. 

The  Rest  Treatment. 

This  form  of  treatment  was  devised  and  perfected  by  Dr.  S. 
Weir  Mitchell  and  has  been  popularized  by  him  and  his  pupils. 
Its  value  in  many  types  of  neurasthenia  and  hysteria,  especially 
among  women,  is  unquestioned.  It  seems  more  difficult  to  apply  it 
to  men,  though  it  is  often  useful  with  them. 

Among  women  it  answers  best  in  my  experience  for  young  women 
or  those  this  side  of  middle  life,  of  net  very  forceful  character  and 
not  very  strong  will.  The  active,  keen-witted,  intellectual  woman 
who  suffers  from  headache,  brain  tire,  and  exhaustion  from  slight 
exertion  does  not  do  so  well  under  a  method  which  for  a  time  ren- 
ders the  patient  entirely  abulic. 

The  essential  features  of  the  rest  cure  are :  Isolation,  diet,  rest 
in  bed,  massage,  electricity,  and  the  energizing  personality  of  a  wise 
physician. 

Isolation.— The  patient  can  rarely  be  treated  successfully  at 
home,  even  if  the  relatives  are  not  allowed  to  see  her.  The  best 
place  is  a  comfortable  room  in  a  boarding-house  or  private  hospital. 
A  private  room  in  a  general  hospital  may  answer.  A  special  nurse 
is  necessary,  and  she  should  be  young,  neat,  careful,  sufficiently  in- 
telligent and  tactful,  but  not  overeducated  or  one  who  feels  too 
keenly  her  social  position.  Decayed  gentlewomen  are  sometimes 
very  interesting  characters,  but  they  make  poor  nurses.  I  am 
afraid  of  nurses  with  an  English  or  Irish  accent.  She  should  be  a 
stranger  to  the  patient,  rather  than  one  who  has  nursed  the  patient 
in  previous  illnesses.  She  should  preferably  know  how  to  give 
massage,  electricity,  and  the  simpler  forms  of  water  treatment. 
The  patient  sees  only  the  doctor  and  a  masseuse  if  the  nurse  does 
not  know  how  to  give  this  treatment. 

The  diet  should  consist  as  far  as  possible  of  milk.  During  the 
first  two  weeks  this  is  especially  important.  Skim-milk  is  used 
and  it  should  be  perfectly  fresh.  Four  ounces  are  given  at  first 
every  two  hours.  This  amount  is  increased  to  two  or  four  quarts 
a  clay.  The  milk  may  be  treated  in  various  ways  in  order  to  make 
it  more  palatable  or  digestible.  The  addition  of  a  little  salt  or 
lime  water,  or  of  tea,  coffee,  or  cocoa,  or  Vichy  water,  accomplishes 
this  end.  It  may  be  varied  with  malted  milk,  dextrmized  barley, 
Xestle's  food,  or  the  milk  may  be  mixed  with  barley  or  rice  water. 
Two  or  four  ounces  of  liquid  malt  may  be  given  before  the  milk 
three  times  a  day.  At  the  end  of  a  week  a  pint  of  beef  tea  is  added. 
It  is  made  (Mitchell)  by  chopping  up  one  pound  of  raw  beef  and 
placing  it  in  a  bottle  with  one  pint  of  water  and  five  drops  of  strong 


NEUROLOGICAL   THERAPEUTICS.  603 

hydrochloric  acid.  This  mixture  stands  all  night,  and  in  the  morn- 
ing the  bottle  is  set  in  a  pan  of  water  at  110°  F.  and  kept  two  hours 
at  about  this  temperature.  Strain  through  a  stout  cloth  and  squeeze 
the  mass  till  nearly  dry.  The  resulting  fluid  is  given  in  three  por- 
tions daily.  If  the  taste  be  objected  to,  the  meat  may  be  roasted  a 
trifle  on  one  side,  or  the  ordinary  commercial  extracts  may  be  used. 
It  is  better  at  first  for  the  patient  to  be  fed  by  the  nurse.  The 
milk  and  other  food  should  be  taken  slowly. 

Rest. — It  is  extremely  important  that  the  patient  be  made  to  go 
to  bed  and  lie  flat  on  her  back,  not  even  sitting  up  to  be  fed.  The 
object  is  not  only  to  secure  absolute  rest,  but  to  make  the  patient 
feel  that  she  is  in  the  hands  of  her  physician,  who  is  to  manage  her 
till  she  is  well.  The  enforced  quiet  also  adds  to  the  desire  later  to 
to  get  well  and  regain  her  freedom.  She  is  to  be  kept  in  bed  for  a 
month ;  then  allowed  to  sit  up  for  ten  minutes  twice  a  day,  this 
time  being  lengthened  by  five  or  ten  minutes  daily.  After  five  or 
six  weeks  she  may  be  allowed  a  drive  or  a  short  walk.  About  this 
time  one  must  also  begin  systematically  to  enforce  walking  and 
other  exercise,  and  the  patient  must  be  taught  to  ignore  the  slight 
pain  and  fatigue  that  at  first  ensue. 

Massage. — The  system  of  massage  recommended  by  Mitchell  is 
simpler  than  that  ordinarily  used  by  the  Swedish  professionals,  and 
consists  mainly  of  kneading  and  centripetal  friction.  It  is  given  at 
least  an  hour  after  a  meal  and  lasts  at  first  fifteen  or  twenty  min- 
utes once  a  day.  In  a  few  days  this  is  increased  to  three-quarters 
of  an  hour  and  an  hour.  The  legs  are  massed  first,  then  the 
abdomen,  chest,  and  arms.  The  head  and  neck  are  not  touched. 
No  ointment  or  lubricating  substance  is  used.  Particular  attention 
is  paid  to  the  abdomen  in  order  to  prevent  constipation.  After 
massage  there  should  be  a  rest  of  an  hour.  After  four  or  eight 
weeks  Swedish  movements  are  added  to  the  massage. 

Electricity. — The  faradic  current  is  used  with  a  primary  coil 
and  a  slow  interrupter.  In  very  sensitive  persons  a  long  secondary 
coil  with  fine  interruptions  is  better.  Electrodes  of  the  "normal" 
size  are  employed  and  each  segment  of  the  limbs  is  gone  over,  be- 
ginning with  the  periphery.  The  two  electrodes  are  placed  over 
the  muscles  a  few  inches  apart  and  each  muscle  is  contracted  four  or 
six  times.  The  question  of  poles  may  be  ignored.  The  feet,  legs, 
abdomen,  back,  and  arms  are  gone  over  successively,  then  the  fine 
secondary  current  is  turned  on.  A  large  electrode,  of  the  "  indiffer- 
ent" size,  is  placed  on  the  back  of  the  neck,  and  the  other  electrode 
placed  on  the  sole  of  one  foot;  a  current  is  passed  for  seven  and  a 
half  minutes ;  then  the  electrode  is  shifted  to  the  other  foot  and  the 


GO-i  DISEASES    OF   THE    NERVOUS    SYSTEM. 

current  given  for  the  same  time.  It  is  best  for  the  physician  him- 
self to  give  the  electricity  if  possible.  The  duration  of  each  seance 
is  from  three-quarters  to  one  hour,  and  it  is  continued  for  six  weeks. 
Very  mild  currents  are  used  at  first. 

The  duration  of  the  rest-cure  should  never  be  less  than  a  month. 
It  is  usually  about  six  or  eight  weeks.  A  typical  schedule  for  a 
rest-cure  patient  as  given  by  Dr.  John  K.  Mitchell  is  the  following: 

7  a.m. — Cocoa. 

Cool  sponge  bath  with  rough  rub  and  toilet  for  the 
day. 

8  a.m. — Milk,  breakfast. 

.  Rest  an  hour  after. 

10  a.m. — 8  oz.  peptonized  milk. 

11  a.m. — Massage. 

12  m. — Milk  or  soup. 

Reading  aloud  by  nurse 
1:30  p.m. — Dinner. 

Rest  an  hour. 
3:30  p.m. — 8  oz.  peptonized  milk. 
4  p.m. — Electricity. 
6  p.m. — Supper  with  milk. 

8  p.m. — Reading  aloud  by  nurse  one-half  hour. 

9  p.m. — Light  rubbing  by  nurse  with  drip  sheet. 

8  oz.  malt  extract  with  meals,  tonic  after  meals. 
8  oz.  peptonized  milk  with  biscuit  at  bedtime  and 
a  glass  of  milk  during  the  night  if  desired. 

Laxative:  cascara,  10  to  30  drops  p.  r.  n.  Later  Swedish  move- 
ments are  added  to  the  massage. 

Additional  Measures. — A  sponge  bath  is  given  every  morning. 
Insomnia  is  to  be  feared  at  the  start,  and  for  this  bromide  of  sodium 
may  be  given  in  doses  of  gr.  xxx.  at  6  and  9  p.m.  and  gradually 
decreased  grain  by  grain;  or  sulphonal  (gr.  xx.  to  xxx.)  in  hot 
water,  or  trional  (gr.  xv.).  Some  form  of  hydrotherapy  may  an- 
swer better  than  drugs,  and  a  favorite  measure  is  the  drip  sheet. 

The  following  are  the  directions  for  its  use  (Mitchell): 

Basin  of  water  at  65°  F.  Lower  the  temperature  day  by  day 
by  degrees  to  55°  F.,  or  to  still  less.  Put  in  the  basin  a  sheet,  let- 
ting the  corners  hang  ouc  to  be  taken  hold  of.  The  patient  stands 
in  one  garment  in  comfortably  hot  water.  Have  ready  a  large  soft 
towel  and  iced  water.  Dip  the  towel  in  this,  wring  it,  and  put  it 
turban-wise  about  the  head  and  back  of  the  neck.  Take  off  night- 
dress. Standing  in  front  of  patient,  the  basin  and  sheet  behind, 
the  maid  seizes  the  wet  sheet  by  two  corners  and  throws  it  around 


XEUEOLOGICAL   THERAPEUTICS.  605 

the  patient,  who  holds  it  at  the  neck.  A  rough,  smart,  rapid  rub 
from  the  outside  applies  the  sheet  everywhere.  This  takes  but  two 
minutes  or  less.  Drop  the  sheet,  let  the  patient  He  down  on  a 
lounge  upon  a  blanket,  wrap  her  in  it,  dry  thoroughly  and  roughly 
with  coarse  towels  placed  at  hand.  Wrap  in  a  dry  blanket.  Re- 
move ice  wrap;  dry  hair;  put  on  nightdress.  Bed,  the  feet  covered 
with  a  flannel  wrap. 

As  tonics,  lactate,  pyrophosphate,  or  subcarbonate  of  iron  are 
given  in  doses  of  gr.  xxx.  daily.  Small  doses  of  strychnine,  salicin 
or  cpiinine,  or  dilute  phosphoric  acid  may  be  useful. 

The  partial  rest-cure  is  indicated  in  the  milder  cases  of  neuras- 
thenia and  hysteria.  The  following  is  the  schedule  given  by  Dr. 
Weir  Mitchell: 

a.m. — On  awaking,  cup  of  cocoa.  Take  bath.  (Temperature 
given.)  Lie  down  on  lounge  while  using  drying-towels;  or,  better, 
be  sponged  and  dried  by  an  attendant.  In  this  process  the  surface 
to  be  rubbed  red,  or,  if  drying  one's  self,  to  use  flesh  brush.  Bed 
or  lounge  again.  Breakfast.  Before  each  meal  take  three  ounces 
of  malt  extract;  aperient  at  need  in  malt.  Tonic  after  each  meal. 
Detail  as  to  breakfast  diet.  If  eyes  are  good,  may  then  read  seated 
in  bed.  At  10  to  11  a.m.,  one  hour's  massage.  Rest  one  hour; 
may  be  read  to,  or  read  if  eyes  are  good,  or  knit.  At  this  time,  11 
a.m.,  four  ounces  of  beef  soup  or  eight  ounces  of  milk.  At  noon 
may  rise,  dress  slowly,  resting  once  or  twice  a  few  minutes  while 
dressing,  and  remain  up  until  3  p.m.  See  children,  attend  to  house- 
hold business;  see  one  visitor,  if  desirable.  From  1  to  1 :30  p.m. 
malt,  etc.,  and  lunch.  Detail  as  to  diet.  At  first,  as  a  rule,  let 
tliis  meal  represent  dinner.  Tonic,  and  after  it  to  rest  on  a  lounge, 
occupied  as  above,  reading  or  being  read  to.  If  possible,  drive 
out  or  use  tramway,  so  as  to  get  air.  Walk  as  little  as  possible. 
On  return  from  drive  repeat  milk  or  soup.  About  o  p. m.,  electric- 
ity, if  used  at  all.  Rest  until  7  P.M.  Supper  at  7  P.M.  Detail  as 
to  meal.  Malt  as  before,  with  or  without  aperient,  as  occasion 
demands.  Tonic.  To  spend  evening  with  family  as  usual.  Bes1 
not  to  use  eyes  at  night  for  near  view.  Bed  at  10  p.m.  No  letters 
to  be  written  for  two  months,  when  most  of  these  details  have  to  be 
revised. 

After  two  months  of  massage  it  should,  in  these  cases,  as  in 
complete  rest,  be  used  on  alternate  days,  and  by  degrees  given  up. 
If  the  nurse  or  masseuse  is  able  to  teach  the  patient  the  use  of 
Swedish  movements,  it  is  desirable  that  these  or  some  definite 
slowly  increased  system  of  chamber  gymnastics  be  continued  for 
months.     Finally,  walking  must  be  resumed  with  slow  and  system- 


606  DISEASES    OF    THE    XERVOUS    SYSTEM. 

atic  increase.     After  the  second  month  write  out  a  schedule  of  less 
restriction,  to  be  followed  for  six  months. 


SPECIAL  THERAPEUTICS. 

Alcoholism. — 

1>  Strychninse  nitrat. , gr.  i. 

Aqua?  destillat., 3  v. 

Acidi  carbolici, gr.  i. 

M.     Sig.   tti,x.  hypodermically  q.  4  h. 


Atropinse  sulph., gr 

Strychninse  nitrat. , 
Glonoini,    . 
Tinct.  strophanth., 


gr.  i£. 

gr.  i. 


■    3iiJ. 
Extr.  cinchon.  fl q.S.  ad  §  vi. 

M.     Sig.    3i.  t.i.d. 

Acute  Alcoholism. — 

1$  Sodii  bromid. , §i. 

Tinct.  capsici, 3  ss. 

Chloral,  hydrat., §  ss. 

Aqua?  menth.  pip., 5  iij. 

M.     Sig.    3  i.  q-  4  h. 

Epilepsy. — A  method  of  treating  epilepsy  has  been  recom- 
mended by  Dr.  P.  Flechsig  as  being  successful  in  some  obstinate 
cases.  It  consists  in  giving  opium  in  doses  of  gr.  ^  t.i.d.,  in- 
creased to  gr.  iij.  or  v.  t.i.d.  This  is  kept  up  for  five  or  six 
weeks.  The  patient  is  then  placed  at  once  on  large  doses  of  bro- 
mide of  potassium.  I  have  found  in  applying  this  treatment  that  a 
short  course  of  opium  enhances  the  subsequent  effect  of  the  bromide. 
It  is  not  always  wise  or  possible  to  give  large  doses  of  opium  for  so 
long  a  time  as  six  weeks. 

I  have  insisted  upon  the  necessity  of  giving  large  doses  of  bro- 
mides for  a  time  in  all  cases  of  epilepsy.  Dr.  Ch.  Fere  recommends 
regularly  a  gradual  increase  of  bromides  from  3  i.  daily  to  2  iv.  or 
Z  v.  Such  doses  diminish  attacks  from  one  or  two  weekly  to  one 
monthly.  The  criteria  to  be  depended  upon  in  advising  such  treat- 
ment are  the  weight  of  the  patient  and  the  number  of  attacks.  If 
the  weight  falls  and  gastric  trouble  ensues,  or  if  the  attacks  are  not 
lessened,  the  drug  should  not  be  increased. 

In  many  cases  it  is  not  wise  to  continue  the  alkaline  bromides 
indefinitely,  on  account  of  the  condition  of  the  bladder  and  urine. 
The  latter  becomes  cloudy,  feebly  acid  or  alkaline,  and  the  bladder 
is  irritable.  The  following  prescription  I  find  most  useful  as  an 
adjunct  to  the  ordinary  formulae  of  bromides: 


NEUROLOGICAL   THERAPEUTICS. 


607 


H 


Acidi  hydrobromici  dil., 
Ferri  bromid., 
Potas.  bromid., 
Sodii  salicylate, 
Spts.  rectincat., 
Glycerol,  pepsin.,    . 
Olei  gaulth.,    . 
Liq.  amnion,  citrat.   (Br.  P.), 
Sig.  i.  dose.     This  may  be  doubled  or  tripled. 


TI],  X.    tO  XX. 

gr.  i. 

gr.  v.  to  x. 

gr.  ij. 

Til  X. 
TH,  X. 

m  h 

V\  XXX. 


Antifebrin  and  sulplwnal  are  drugs  which  sometimes  control  the 
convulsions.  Antifebrin  may  be  given  in  the  form  of  a  five-grain 
tablet  ter  in  die  with  a  bromide  solution.  Sulphonal  is  given  best 
in  the  form  of  a  powder  at  night.  Fifteen  to  twenty  grains  can  be 
administered  then,  I  do  not  think  the  drug  a  very  useful  one. 
Trional  in  fifteeen-grain  doses  is  better. 

The  following  are  some  special  prescriptions  which  may  be  used 
in  epilepsy : 

I?  Anti  pyrin 3  iss. 

Amnion,  bromid., 3  xvi. 

Aqua;, =  iv. 

M.     Sig.    3  ij-  t.i.d. 

To  be  used  without  other  medication  except  tonics. 

IJ  Beta-naphthol,  .         .         .         .         .         .         .         .   3  i. 

Bismuth,  salicylat. , 3  ss. 

M.  Sig.  i.  daily  in  two  doses  with  3  i.  to  3  v.  potas.  bromide  daily  or 
with  gr.  xlv.  borax. 

IJ  Ext.  belladonn., 

Stunnii  oxid 

M.     Div.  in  pil.  No.  lx.     Sig.  i.  a.m.  and  p.m. 
To  be  used  with  bromides. 

IJ  Trional, 

Sodii  bromid 

M.     Big.  i.  <losc. 

At  night  in  nocturnal  epilepsy. 

Pure  bromine  combined  with  end-liver  oil  or  sesame  oil  can  be 
given  in  doses  of  gr.  x.  to  gr.  xxx..  and  sometimes  acts  well.  Re- 
moval  of  salt  from  the  diet  is  thoughl  important  by  some. 

The  Surgical  Treatment  of  Epilepsy. — This  is  indicated  only  in 
traumatic  forms  of  comparatively  recent  character,  before  more  than 
twenty -five  fits  have  occurred.  It  is  much  more  indicated  in  local 
or  Jacksonian  epilepsy. 

The  mortality  from  the  operation  is  seven  per  cent.  Among  159 
cases  collected  by  Laurent  and  Agnew  there  were  58  cured,  52  im- 
proved,  28  unimproved,   11  died.     Among   42  cases  collected  by 


gr. 

XV. 

3i. 

gr. 

XV. 

gr. 

XX. 

608  DISEASES   OF   THE    NERVOUS    SYSTEM. 

Starr  ("Brain  Surgery  ")  there  were  13  cured,  11  improved,  15  not 
improved,  3  died.     The  term  "  improved"  has  little  meaning. 

Hysteria. — 

I?  Ziuci  valerianat. , ,    .  3iij. 

Ext.  sumbul., 3  ss. 

Quiniiue  sulph 3i. 

M.     Div.  in  capsular  No.  lx.     Sig.  i.  t.i.d. 

1$  Spts.  amnion,  aromat., 

Spts.  lavandul.  co.; 

Spts.  ether,  co.,  .        . aa  §  i. 

M.     Sig.  3i.  p.r.n. 

Apomorphine  ^  gr.  hypodermatically  and  pilocarpine  y1^  gr.  in 
the  same  way  often  break  up  a  hysterical  crisis. 

Impotence. — In  the  treatment  of  impotence  by  electricity  the 
galvanic  or  faradic  current  may  be  used.  My  own  method  is  to 
combine  the  two,  using  the  De  Watteville  switch.  The  positive 
pole  with  a  large  electrode  is  placed  over  the  dorso-lumbar  region, 
the  negative  pole  with  normal  or  large  electrodes  is  placed  on  the 
perineum.  A  current  of  from  5  to  10  milliamperes  is  turned  on. 
Then  the  faradic  current  is  added.  The  secondary  long  coil  with  fine 
vibration  may  be  employed  if  there  is  much  irritability ;  the  short 
coil  with  coarse  vibrations  if  there  is  anaesthesia  or  great  insensi- 
bility. The  current  is  passed  with  occasional  interruptions  for  five 
minutes.  The  lower  electrode  is  then  moved  for  a  time  to  the  root 
of  the  penis  and  the  current  passed  for  a  minute.  A  steel  sound  as 
large  as  the  urethra  will  hold  is  then  introduced  and  the  lower 
(negative)  electrode  connected  with  it.  The  galvanic  current  is  re- 
duced to  2  or  3  milliamperes,  the  faradic  made  as  strong  as 
the  patient  can  stand  it.  The  application  lasts  two  or  three 
minutes. 

In  addition  I  employ  hypodermic  injections  of  strychnine,  or 
cantharidate  of  potassium  (gr.  $faj).  Cupping  and  ligature  of  the 
dorsal  veins  have  been  successfully  used. 

New  Drugs  for  Insomnia. — There  are  no  good  medicines  for 
insomnia,  but  the  following  may  be  occasionally  used : 

Amijl  11 ' yO rate. — This  is  a  fairly  good  and  safe  hypnotic,  but 
disagreeable  to  the  taste.  The  dose  is  about  a  drachm,  given  in 
syrup  and  water.  It  has  a  pungent  taste  like  paraldehyde  and 
sometimes  disturbs  the  stomach. 

Chloral -(uniOe,  is  a  good  hypnotic,  acting  like  chloral  hydrate, 
but  more  slowly.     It  is  less  irritating  and  is  safer  than  chloral, 


NEUROLOGICAL   THERAPEUTICS.  600 

though  the  dangers  of  the  latter  drug  are  very  slight.  The  dose  is 
15  to  45  grains  in  powder  or  dissolved  in  alcohol  or  tincture  of 
cardamom. 

Duboisine  sulphate  has  been  warmly  recommended  as  a  hypnotic 
in  doses  of  gr.  -gL  to  gr.  -fa.  It  has  about  the  same  effect  as  hyos- 
cine. 

Trional  is  a  disulphone,  or  diethylsulphon-methylethylmethan. 
It  is  closely  related  chemically  and  therapeutically  to  sulphonal. 
It  is  a  white  powder  slightly  soluble  in  water  and  best  given  in 
milk  or  wine.  It  acts  in  from  ten  to  thirty  minutes  and  produces 
a  quiet  sleep.  It  is  an  excellent  hypnotic,  ranking  with  sulphonal 
and  having  the  advantage  of  acting  more  promptly.  The  dose  is 
from  10  to  40  grains.     At  least  30  grains  are  needed  in  bad  cases. 

Locomotor  Ataxia. — Erb  has  recently  reported  many  cases 
showing  that  the  inunction  of  mercury  is  followed  by  decided  benefit 
in  this  disease.  He  accompanies  or  follows  the  "  cure"  with  elec- 
tricity >  nitrate  of  silver,  baths,  and  tonics. 

Leyden  has  strongly  advocated  what  may  be  called  the  tonic, 
expectant,  and  training  treatment  of  tabes.  He  does  not  expect 
much  of  drugs,  but  depends  on  diet,  baths,  exercise,  and  quiet. 
This  is  very  well  so  far  as  it  goes,  but  is  a  most  unfortunate  view 
as  a  whole,  for  it  takes  no  account  of  the  fact  that  in  tabes  there  is 
a  specific  something  continually  at  work  eating  away  the  spinal 
cord.  The  physician  must  find  an  agent  to  counteract  this.  Rest 
and  proper  nourishment  and  exercise  do  it  to  some  extent. 

The  Bonuzzi  method  of  stretching  the  spinal  cord  is  advocated 
by  Benedict.  It  is  only  a  modification  of  subcutaneous  stretching 
and  was  practised  in  my  clinic  ten  years  ago.  The  patient  lies  upon 
the  back,  the  head  maintained  in  an  elevated  position  by  a  bolster; 
the  lower  extremities  are  then  flexed  upon  the  body,  forming  a 
semicircle,  the  knees  being  placed  upon  the  chest  of  the  patient  and 
the  legs  held  straight;  the  operator  seizing  the  diverging  ankles 
carries  them  strongly  toward  the  floor.  This  apparently  difficult 
manoeuvre  is  in  reality  easily  executed. 

The  Exercise  Treatment  of  Locomotor  Ataxia. — The  treatment 
of  locomotor  ataxia  by  means  of  systematic  exercises  for  training 
the  ataxic  limbs  often  produces  some  very  satisfactory  results. 
The  method  was  elaborated  first  by  Dr.  Fr&nkel,  and  still  further 
by  Dr.  Hirschberg.  For  the  convenience  of  students  and  readers, 
a  schedule  of  the  exercises  which  I  prescribe,  and  which  are  based, 
more  or  less,  upon  those  of  the  authors  mentioned,  is  appended 
here. 

39 


610  DISEASES   OF   THE    NERVOUS    SYSTEM. 

The  exercises  are  usually  to  be  taken  twice  a  day,  and  each 
exercise  is  to  be  done  with  the  utmost  care  and  precision  by  the 
patient. 

Exercises  for  the  Hands  and  Arms. — 1.  Sit  in  front  of  a  table, 
place  the  hand  upon  it,  then  elevate  each  finger  as  far  as  possible. 
TheD,  raising  the  hand  slightly,  extend  and  then  flex  each  finger 
and  thumb  as  far  as  possible.  Do  this  first  with  the  right  and  then 
with  the  left.     Repeat  once. 

2.  With  the  hand  extended  on  the  table,  abduct  the  thumb  and 
then  each  finger  separately,  as  far  as  possible.     Repeat  three  times. 

3.  Touch  with  the  end  of  the  thumb  each  finger  tip  separately 
and  exactly.  Then  touch  the  middle  of  each  phalanx  of  each  of 
the  four  fingers  with  the  tip  of  the  thumb.     Repeat  three  times. 

4.  Place  the  hand  in  the  position  of  piano  playing  and  elevate 
the  thumb  and  fingers  in  succession,  bringing  them  down  again,  as 
in  striking  the  notes  of  the  piano.  Do  this  twenty  times  with  the 
right  hand,  and  same  with  the  left. 

5.  Sit  at  a  table  with  a  large  sheet  of  paper  and  pencil,  make  four 
dots  in  the  four  corners  of  the  paper  and  one  in  the  centre.  Draw 
lines  from  corner  dots  to  centre  dot  with  right  hand ;  same  with  left. 

6.  Draw  another  set  of  lines  parallel  to  the  first,  with  the  right 
hand;  same  with  left. 

7.  Throw  ten  pennies  upon  the  paper,  pick  them  up  and  place 
them  in  a  single  pile  with  the  right  hand;  then  with  the  left; 
repeat  twice. 

8.  Spread  the  pennies  about  on  the  table,  touch  each  one  slowly 
and  exactly  with  the  forefinger  of  right  hand ;  then  with  forefinger 
of  left. 

9.  Place  an  ordinary  solitaire  board  on  the  table,  with  the  mar- 
bles in  the  groove  around  the  holes.  Put  the  marbles  in  their  places 
with  right  hand;  same  with  left  hand.  Patient  may,  with  advan- 
tage, practise  the  game  for  the  purpose  of  steadying  his  hands. 

10.  Take  ordinary  fox-and-geese  board  with  holes  and  pegs,  and, 
beginning  at  one  corner,  place  the  pegs  in  the  holes,  one  after  the 
other,  using  first  the  right  hand,  then  the  left. 

These  exercises  should  be  gone  through  with  twice  a  day,  and 
should  be  done  slowly  and  carefully,  with  a  conscious  effort  every 
time  of  trying  to  do  one's  best. 

Exercises  for  the  Body  and  Lower  Limbs. — 1.  Sit  in  a  chair,  rise 
slowly  to  erect  position,  without  help  from  cane  or  arms  of  chair. 
Sit  down  slowly  in  the  same  way.     Repeat  once. 

2.  Stand  with  cane,  feet  together,  advance  left  foot  and  return 
it.     Same  with  right.     Repeat  three  times. 

3.  Walk  ten  steps  with  cane,  slowly.  Walk  backward  five 
steps  with  cane,  slowly. 

4.  Stand  without  cane,  feet  a  little  spread,  hands  on  hips.  In 
this  position  flex  the  knees,  and  stoop  slowly  down  as  far  as  pos- 
sible, rise  slowly;  repeat  twice. 


NEUROLOGICAL   THERAPEUTICS.  611 

5.  Stand  erect,  carry  left  foot  behind,  and  bring  it  back  to  its 
place;  the  same  with  the  right.     Repeat  three  times. 

6.  Walk  twenty  steps,  as  in  exercise  No.  3 ;  then  walk  back- 
ward five  steps. 

7.  Repeat  exercise  No.  2,  without  cane. 

8.  Stand  without  cane,  heels  together,  hands  on  hips.  Stand 
in  this  way  until  you  can  count  twenty.  Increase  the  duration 
each  day  by  five,  until  you  can  stand  in  this  way  while  one  hun- 
dred is  being  counted. 

9.  Stand  without  cane,  feet  spread  apart;  raise  the  arms  up 
from  the  sides  until  they  meet  above  the  head.  Repeat  this  three 
times.  With  the  arms  raised  above  the  head,  carry  them  forward 
and  downward,  bending  with  the  body  until  the  tips  of  the  fingers 
come  as  near  the  floor  as  they  can  be  safely  carried. 

10.  Stand  without  cane,  feet  spread  apart,  hands  on  hips ;  flex 
the  trunk  forward,  then  to  the  left,  then  backward,  then  to  the 
right,  making  a  circle  with  the  head.     Repeat  this  three  times. 

11.  Do  exercise  No.  9  with  heels  together. 

12.  Do  exercise  No.  10  with  heels  together. 

13.  Walk  along  a  fixed  line,  such  as  a  seam  on  the  carpet,  with 
cane,  placing  the  feet  carefully  on  the  line  each  time.  Walk  a  dis- 
tance of  at  least  fifteen  feet.     Repeat  this  twice. 

14.  Do  the  same  without  cane. 

15.  Stand  erect  with  cane;  describe  a  circle  on  the  floor  with 
the  toe  of  right  foot.     Same  with  toe  of  left.     Repeat  twice. 

Between  the  fifth  and  sixth  exercises  the  patient  should  rest  for 
a  few  moments. 

Masturbation. — An  efficient  remedy  against  this  practice  is  to 
insert  a  piece  of  silver  or  copper  wire  through  a  portion  of  the  fore- 
skin at  the  edge  of  the  glans.  This  is  a  rather  heroic  measure  and 
called  for  more  especially  in  those,  suffering  from  mental  deteriora- 
tion or  insanity.  A  somewhat  less  severe  measure  is  to  paint  the 
glans  with  cantharidal  collodion. 

Lumbar  Punctube  <>k  the  Spinal  Cord Paracentesis  of  the 

spinal  dura  mater  has  been  recommended  by  Quincke  and  Ziemssen 
for  the  treatment  of  meningitis  with  serous  effusion.  The  relief  ob- 
tained is  usually  but  temporary,  but  the  measure  may  be  of  help  in 
diagnosis.  I  have  tried  it  in  a  few  cases  with  negative  results,  but 
have  found  that  the  operation  is  not  difficult  or  dangerous  if  care- 
folly  done. 

Quincke's  directions  concerning  the  operation  should  be  followed 
— that  is,  the  patient  should  lie  on  his  left  side  with  his  lumbal 
spine  flexed  well  forward;  the  needle  is  cautiously  inserted  to  a 
depth  of  5  cm.  between  the  arches  of  the  third  and  fourth  or  fourth 
and  fifth  lumbar  vertebrae  near  the  spinous  processes. 

Multiple  Neuritis. — The  pains  and  sensitiveness  of  the  early 
stage  may  be  met  with  powders  of  the  following: 


612  DISEASES   OF   THE   NERVOUS    SYSTEM. 

T$  Salophen,  gr.  xv.,  4  in  die  ; 
or 

I£  Sodii  iodid., 

Sodii  salicylat., 

Antipyrin, aa  gr.  v. 

M.     Sig.  i.  three  to  four  times  daily. 

Salicylate  of  potassium  or  sodium  in  large  doses  sometimes  helps 
the  pain,  but  as  a  rule  it  does  no  good.  Croton  chloral  in  doses  of 
gr.  v.  may  be  used  for  a  time.  Later  one  should  give  ferric  iodide 
and  potassium  iodide  in  small  doses  every  four  hours,  alternating 
•with  phosphorus  (gr.  ^L).  Still  later,  that  is  to  say,  five  or  six 
weeks  after  full  development  of  the  disease,  give  hypodermic  injec- 
tions of  strychnine.  If  the  patient  is  very  alcoholic  I  give  strych- 
nine in  the  first  week.  Static  sparks,  galvanism,  or  faradism 
should  also  be  administered  in  brief  daily  seances  for  a  period  of  six 
weeks.  Galvanism  is  best  used  first,  later  fine  high  potential  fara- 
dic  currents  or  sparks. 

Drugs  for  Neuralgia,  Headache,  Painful  Affections. — 
So  far  as  I  have  been  able  to  discover,  none  of  the  new  drugs  sur- 
pass in  value  antipyrin,  antifebrin,  and  phenacetin,  or  chloral, 
chloralamid,  paraldehyde,  and  sulphonal.  Some  of  them  are,  how- 
ever, useful  in  combination  or  alternation  with  the  older  prepara- 
tions ;  some  are  more  palatable,  convenient,  or  may  cause  fewer 
unpleasant  symptoms.  It  is  to  be  supposed  that  most  of  the  new 
drugs  have  some  commercial  house  behind  them  which  is  interested 
in  popularizing  their  use.  This  has  to  be  considered  in  estimating 
the  value  of  some  published  reports. 

External  Applications   for  Pain. — 

1$  Spts.  chloroformi 3  ij. 

Alcohol §iij. 

Menthol,    .         .  3  vi. 

M.     Sig.  Ext.  use. 

Paint  on  part  and  cover  with  bandage. 

Sciatica. — In  chronic  and  in  early  cases  the  rest  treatment  as 
indicated  in  the  body  of  my  book  will  usually  be  of  most  service. 

The  leg  should  be  carefully  and  firmly  enveloped  in  a  flannel 
bandage  from  toe  to  hip.  Then  a  Thomas  splint  is  applied.  Every 
day  the  splint  is  removed  and  the  leg  cautiously  exercised.  At  the 
end  of  two  or  three  weeks  the  patient  can  be  allowed  to  use  the 
limb  himself  for  a  time.  With  the  flannel  bandage,  an  ice  bag  or 
hot-water  bag  is  not  always  needed. 

The  experience  of  the  clinic  at  La  Salpetriere  is  that  suspension 
does  good  service  in  sciatica. 


NEUROLOGICAL   THERAPEUTICS.  613 

Tic  Douloureux. — Local  injections  of  five  or  ten  drops  of  four- 
per-cent  or  two-per-cent  solution  of  cocaine  often  give  relief  for  a 
considerable  time.  The  chloride  of  methyl  spray  or  a  bit  of  cotton 
wet  with  the  methyl  and  drawn  over  the  affected  area  until  it  is 
frozen  will  prove  helpful.  I  have  also  found  the  Granville  per- 
cuteur  gently  applied  for  five  or  ten  minutes  of  service.  Along  with 
such  measures  one  should  give  pills  of  aconitine  gr.  ^fa  every  four 
hours  and  a  tonic  as  follows : 

I£  Acidi  phosphor,  dil. , §  i. 

Ferri  pyrophosphat. , 3  i. 

Quininse  sulph.,        ' 3  i.  to  3  ij. 

Aquae §  iij. 

M.     Sig.    3i.  t.i.d. 

Croton  chloral  in  doses  of  five  to  fifteen  grains  three  times  a  day 
may  be  substituted  for  the  aconitine,  and  codeine  or  cannabis  indica 
combined  with  it. 

In  cases  of  not  too  long  standing,  rest  and  the  hypodermic  injec- 
tion of  strychnine,  as  described  in  the  body  of  this  work,  should 
always  be  prescribed. 


INDEX. 


Abdtjcens  nerve,  anatomy  of  the,  99 

paralysis  of  the,  107 
Abscess  cerebral,  407 
Acoustic  nerve,  anatomy  of  the,  186 

neuroses  of  the,  187 
Acrania,  390 
Acrodynia,  90 
Acromegaly,  569 
Acroparesthesia,  153 
Actinomycosis  of  the  brain,  455 
iEsthesiometei ,  53 
After  brain,  344 
Age  as  a  factor  in  the  etiology  of 

nervous  diseases,  24 
Ageusia,  195 
Agraphia,  388,  389 
Akinesia,  akinesis,  35 

algera,  505 
Alcoholism,  treatment  of,  606 
Alexia,  387,  390 
Allochiria,  definition  of,  37 
Amaurosis,  168 
Amblyopia,  168 
Amimia,  388 
Amnesia,  hysterical,  489 
Ampere,  definition  of,  68 
Amperemeter,  69 
Amputation  neuroma,  96 
Amyelia,  237 

Amyostlicniu,  hysterical,  494 
Amyotrophic  lateral  sclerosis,  318 
Amyotrophy,  progressive  spinal.  309. 
Anaemia,  cerebral,  406 

in  hysteria,  4!)S 

meningeal,  392 

pernicious,  combined  spinal  Bcle 
roses  of,  299 

spinal,  243 
Anaesthesia,  definition  cf,  31 

hysterical,  491 


Anaesthesia,  muscular,  36 

trigeminal,  176 
Analgesia,  definition  of,  36 
Anatomy,    general,    of    the    nervous 

system,  1 
Aneurisms,  intracranial,  457,  459 

miliary,  of  the  brain,  430,  459 
Angio-ataxia,     -neurosis,    -paralysis, 

and  -spasm,  definition  of,  37 
Angioneurotic    gangrene,   symmetri- 
cal, 205 

oedema,  575 
Angiopathic  neurasthenia,  533 
Anidrosis,  definition  of,  37 
Ankle  clonus,  51 
Anosmia,  161 
Anxiety  neurosis,  532 
Aphasia,  386 

auditory,  387,  389 

conduction,  388,  390 

cortical  sensory,  388 

mixed,  390 

motor,  388,  389 

subcortical,  390 

visual,  386,  390 
Aphemia,  384,  385,  388,  389 
Aphonia,  hysterical,  494 
Aphthongia,  129 
Apoplexy,  cerebellar,  429 

diagnosis  of  the  varieties  of,  432 

dural,  428 

embolic,  434 

hemorrhagic,  422 

meningeal,  427 

pial,  429 

pons,  429 

spinal,  238 

thrombotic,  434 
Apraxia,  387 
Arachnoid,  cerebral,  366 


616 


INDEX. 


Arachnoid,  spinal,  208 
Arbor  vitae  of  the  cerebellum,  358 
Arcades,  interfascicular,  15 
Argyll-Robertson  pupil,  51,  107 

in  locomotor  ataxia,  280 
Arms,  cord  centres  for  muscles  of  the, 
227 
palsies  of  the,  136 
spasmodic  disorders  of  the,  136 
Arteries,  cerebral,  367 

spinal,  229,  232 
Arthropathy  of  locomotor  ataxia,  281 

pneumogenic  osteo-,  571 
Associated  movements,  34 
Association  centres  in  the  brain,  362 
Associative  functions  of   the  brain, 

377 
Astereognosis,  36 
Asthenopia,    muscular,    of    the  eye, 

108 
Ataxia,  cerebellar,  36 
definition  of,  36 
family,  301 
Friedreich's,  300 
hereditary  cerebellar,  306,  327 

spinal,  300 
locomotor,  see  Locomotor  Ataxia 
motor,  36,  274 

testing  for,  58 
static,  36 

testing  for,  58 
tests  for,  55 
Ataxiagraph,  58 
Athetosis,  34 

Atrophia  musculorum  lipomatosa,  321 
Atrophies,  progressive  muscular,  308 
Atrophy,  arthritic  muscular,  327 
occupation  muscular,  328 
optic,  167 

progressive  muscular,  309 
hereditary,  327 
hereditary,  of  leg  type,  314 
infantile,  325 
spastic  form  of,  318 
Auditory  nerve,  anatomy  of  the,  186 

neuroses  of  the,  186 
Auditory  vertigo,  190 
Aura,  epileptic,  476,  478 
Automatism,  cerebral,  in  hysteria,  489 


Axis  cylinder,  5,  11,  16 
Axon,  5 

Babinski,  sign  of,  47 

Back,  cord  centres  for  muscles  of  the, 
229 

Baillarger,  stripe  of,  351,  352 

Ballet-dancers'  cramp,  558 

Basedow's  disease,  544 

Baths  in  the  treatment  of   nervous 
diseases,  62,  65,  597 

Batteries,  electric,  69 

Beard's  disease,  519 

Bell's  palsy,  115 

Beriberi,  90 

Birth  palsies,  441 

Blepharospasm,  115 

Blindness,  mind,  387 
word,  387 

Blood  supply  of  the  brain,  367 

Blood-vessels  of  the  peripheral  nerves, 
15 

Brachial  nerve,  paralysis  of  the,  136 

Brachial  plexus,  anatomy  of  the,  135 

Brachycephalic,  definition  of,  42 

Brain,  abscess  of  the,  407 
chronic,  409 
actinomycosis  of  the,  455 
ansemia  of  the,  406 
anatomy  of  the,  343 
aneurisms  of  the,  430,  457 
association  centres,  362 
associative  function  of  the,  377 
bilateral  representation,  373 
blood  supply  of  the,  367 
cancer  of  the,  456 
central  lobe,  349 
centres  in  the,  372 
centrum  ovale,  377 
cerebellum,  358,  378 
compression  symptoms,  385 
convolutions  of  the,  346 
corpora  quadrigemina,  357,  378 
corpora  striata,  353,  377 
corpus  callosum,  377 
cortex  of  the,  346,  350 
cranio-cerebral  topography,  592 
cutting  the,  381 
cysticerci  of  the,  457 


INDEX. 


017 


Brain,  development  of  the,  343 

diagram  of  the  divisions  of  the,  2 
diseases  of  the,  385,  405 

membranes  of  the,  392 
echinococcus  of  the,  457 
embolism  of  the  arteries  of  the, 

434 
fibres  of  the  cortex,  352 
fibroma  of  the,  456 
fissures  of  the,  346,  34? 
focal  symptoms,  385 
frontal  lobe,  347 
functions  of  the,  372 
ganglionic  deposits  of  the,  346 
glioma  of  the,  455 
gumma  of  the,  454 
hemorrhage  in  the,  422,  423 

membrane  of  the,  422,  423, 
427 
hyperemia  of  the,  405 
inflammation  of  the,  407 
irritation  symptoms,  385 
latent  regions  of  the,  377,  379 
limbic  lobe,  349 
lobes  of  the,  :;47 
localization  in  the,  372 
Luys'  body,  358 
malformations  of  the,  390 
meninges  of  the.  866 

diseases  of  tin.',  392 

hemorrhage  in  the,  427 
miliary  aneurisms  of  the,  430 
motor  tracts  in  the,  362 
occipital  lobe,  347 
olfactory  lobe,  350 
operculum,  350 
optic  thalami,  354 
osteoma  of  the,  456 
palsies  of  children,  487 
parasitic  growths  in  the,  457 
parietal  lobe,  '■'> IT 
plexuses  of  the  cortex,  352 
preserving  the.  881 
projection  system,  362 
red  nucleus,  :r>s,  :}78 
sarcoma  of  the.  156 
sensori-motor  ana,  872 
sensory  tracts  in  the,  364 
softening  of  the,  acute,  434 


Brain,  substantia  nigra,  357 
subthalamus,  358 
symptoms  of  disease  of  the,  385 
syphilis  of  the,  461 
syphiloma  of  the,  454 
temporal  lobe,  348 
thalamus  opticus,  377 
thrombosis  of  the  arteries  of  the, 

434 
topography  of  the,  592 
tubercle  of  the,  454 
tumors  of  the,  445 

focal  symptoms  of,  448 
multiple,  454 

of  the  basal  ganglia  and  cap- 
sule, 451 
of  the  base,  453 
of  the  central  area,  449 
of  the  cerebellum,  453 
of  the  corpora  quadrigemina, 
deep   marrow,  and   pineal 
gland,  451 
of  the  corpus  callosum,  451 
of  the  crus,  452 
of  the  occipital  lobes,  450 
of  the  optico-striate  region, 

451 
of  the  parietal  area,  450 
of  the  pons  and  medulla,  452 
of  the  prefrontal  area,  448 
of  the  temporal  area,  450 
weight  of  the,  380 
wet,  401 
Brauch-Romberg  symptom,  58 
Bulbar  paralysis,  asthenic,  316 
progressive,  314 
upper,  107 
Bulbospinal  paralysis,  asthenic,  316 
Burdach,  column  of,  216,  219 

Caisson  disease,  240 

Cajal's  cells,  8 

Cancer  of  the  brain.  456 

of  the  spinal  cord,  331 
Caput  obstipum,  128,  L82 
Catalepsy,  589 

hysterical,  489 
Cauda  equina,  anatomy  and  diseases 
of,  339 


618 


INDEX. 


Cauda    equina,    lesions    at  different 

levels,  341 
Causes  of  nervous  diseases,  23 
Cells,  Cajal's,  8 

cerebral  cortical,  350 

Deiter's,  8 

Golgi's,  8,  361 

nerve,  5 

neuroglia,  13 

of  the  spinal  cord,  212 

Purkinje's,  359 

scavenger,  of  Lewis,  14 

spider,  13 

stellate,  of  the  cerebellar  cortex, 
359 
Central  nervous  fibres,  13 
Centres,  cerebral,  372 

spinal,  220 
Centrosome    and    centrosphere  of    a 

peripheral  nerve  cell,  8 
Centrum  ovale,  377 
Cephalalgia,  176 

hydrotherapy  in,  599 

location  of  pain  according  to  the 
cause,  179 

treatment,  612 
Cerebellar  ataxia,  hereditary,  306 
Cerebellum,  abscess  of  the,  410 

anatomy  of  the,  358 

functions  of  the,  378 

gray  matter  of  the,  359 

hemorrhage  in  the,  429 

tumors  of  the,  453 

white  matter  of  the,  361 
Cerebrospinal  irritation,  531 

meningitis,  395 

multiple  sclerosis,  416 
aborted  types  of,  418 

syphilis,  463 
Cervical  nerves,   motor   neuroses  of 
the,  132,  136 

sensory  neuroses  of  the,  196,  197 
Charcot  Marie    type    of    progressive 

hereditary  muscular  atrophy,  314 
Chemistry  of  the  nervous  system,  22 
Chiasm,  optic,  163 
Choked  disc,  165 
Chorea,  507 

chronic,  509 


Chorea,  dancing,  513 

diagnosis,  511 

duration,  509 

electric,  512 

etiology,  507 

forms,  509 

habit,  512 

hereditary,  326,  512 

Huntington's,  512 

insaniens,  509 

major,  513 

maniacal,  509 

of  the  larynx,  503 

paralytic,  509 

pathology,  510 

procursive,  513 

prognosis,  511 

relapses,  509 

senile,  509 

Sydenham's,  507 

symptoms,  508 

treatment,  511 
Choreic  movements,  34 
Chromophilic  granules  of  the  nerve 

cell,  7 
Cigarmakers'  cramp,  557 
Circumflex  nerve,  paralysis  of  the, 

141 
Civilization  as  a  factor  in  the  etiology 

of  nervous  diseases,  25 
Climate  as  a  factor  in  the  etiology  of 
nervous  diseases,  25 

in  the  treatment  of  nervous  dis- 
eases, 66 
Clarionet  players'  cramp,  557 
Clarke's  column,  212,  220 
Clonus,  ankle,  51 
Coagulation  necrosis,  29 
Coccygodynia,  205 
Cold,  effect  of,  in  the  treatment  of 

nervous  diseases,  63 
Columns  of  the  spinal  cord,  210,  212, 

215,  220 
Coma,  apoplectic,  423 

trance,  585 
Conjugate  deviation  of  the  eyes,  defi- 
nition of,  103 

spasmodic,  110 
Contraction,  paradoxical,  51 


INDEX. 


619 


Contracture,  definition  of,  34 

hysterical,  495 
Convulsions,  33 

epileptic,  476 

hysterical,  489,  501 
Coprolalia,  503 
Cord,  spinal,  see  Spinal  Cord 
Corpora  quadrigemina,  357,  378 

tumors  of  the,  451 
Corpus  callosum,  377 

tumors  of  the,  451 
Corpus  striatum,  353,  377 
Cortex,  cerebellar,  359 
Cramps,  33 

occupation,  551 
Craniocerebral  topography,  592 
Cranium,   table  of  measurements  of 

the,  43 
Cretinism,  573 

Crises  in  locomotor  ataxia,  283 
Crura  cerebri,  tumors  of  the,  452 
Current,   electrical,  employed  in  the 
treatment  of  nervous  dis- 
eases, 67,  600 
primary  induced,  70 
secondary  induced,  70 
Current  strength,  definition  of,  68 
Cyclopia,  390,  392 
Cycloplegia,  106 
Cyrtometers,  592 
Cysticerci  of  the  brain,  457 
Cytoplasm,  7,  22 

Dead  fingers,  207 

in  writers'  cramp,  554 
Deafness,  nervous,  187 

word,  387,  389 
Degenerates,  24 

Degeneration,  neuritic,  complicating 
forms  of,  94 

of  nerves,  80 

of  nervous  tissue,  28 

reactions  of,  74 

stigmata  of,  41 

varieties  of,  29 
Deiter's  cells,  8 
Dementia  paralytica,  467 
Dendrites,  6,  16,  17 

cellulipetal  impulses  in  the,  16, 17 


Diagnosis  of  nervous  diseases,  39 

electro-,  74 
Diaphragm,  paralysis  of  the,  133 
Diathesis  as  a  factor  in  the  etiology 
of  nervous  diseases,  25 

<"ontractural,  495 
Diencephalon,  3,  344 
Diet  employed  in  the  rest  treatment, 
604 

for  the  neuropathic,  61 
Digiti  mortui,  207 

in  writers'  cramp,  554 
Diplegia,  definition  of,  35 

hereditary  cerebral,  326 

infantile,  437 
Diplopia,  definition  of,  103 
Divers'  paralysis,  240 
Dizziness,  190 

Dolicocephalic,  definition  of,  42 
Dorsal  nerves,  anatomy  of  the,  147 

motor  neuroses  of  the,  147 
Douche,  use  of,  in  the  treatment   of 

nervous  diseases,  62 
Dreams,  582 
Drivers'  spasm,  557 
Dropfoot,  151 
Dropsy,  sleeping-,  591 
Drowsiness,  morbid,  588 
Drunkenness,  sleep-,  583 
Duchenne-Aran's  disease,  309 
Dura  mater,  cerebral,  366 

infiammation  of  the,  392 

spinal,  208 

infiammation  of  the,  243 
Dynamometer,  45 
Dysacusis,  194 

Dysesthesia,  definition  of,  36 
Dysphagia,  121 
Dystrophies,  568 

hereditary,  327 

juvenile,  of  Erb,  325 

progressive  muscular,  390 

Eah,  neuroses  of  the,  186 
EchinoCOCCUB  of  the  brain,  457 
Echokinesis,  508 
Echolalia,  508 
Eclampsia,  475 
nutans,  127 


620 


INDEX. 


Electricity,  appliances  for  the  thera- 
peutic use  of,  69 

employed  in  the  rest  treatment, 
603 

in  the  treatment  of  nervous  dis- 
eases, 67,  600 

methods  of  application  of,  71 

terms  employed  in  relation  to,  68 
Electrodes,  71 
Electro-diagnosis,  74 
Electromotive  force,  definition  of,  68 
Electrotherapeutics,  77 
Electrotonus,  21 
Embolism,  cerebral,  434 
Encephalitis,  acute  exudative,  of  the 
gray  matter,  413 
with  hemorrhage,  413 

acute  suppurative,  407 

chronic  suppurative,  409 

hemorrhagic,  413 
Endoneurium,  10 
Enteritis,  mucous,  528 
Enteroptosis,  528 
Epilepsy,  474 

abortive  attack,  478 

aura,  478 

complicating    infantile  hemiple- 
gia, 438 

course,  482 

diagnosis,  481 

etiology,  475 

grand  mal,  475,  482 

hydrotherapy  in,  598 

hystero-,  475 

idiopathic,  474 

Jacksonian,  475,  478 

laryngeal,  194 

matutinal,  479 

mental  condition  in,  479 

minor  attack,  478 

partial,  478 

pathology,  480 

petit  mal,  477 

physical  condition  in,  479 

physiology,  481 

procursive,  477 

prognosis,  482 

psychical,  477 

severe  attack,  476 


Epilepsy,  sleep-,  589 

somnambulic,  478 

surgical  treatment,  607 

symptomatic,  475 

symptoms  of  the  convulsion,  476 

treatment,  482,  606 
Erb's  juvenile  dystrophy,  325 

palsy,  139 
Erroneous   projection,   definition  of, 

103 
Erythromelalgia,  204 
Etiology  of  nervous  diseases,  23 
Examination,  method  of,  in  nervous 

disease,  39 
Exercise  for  the  neurasthenic,  62 
Exophthalmic  goitre,  544 
Eye,  attachment  of  the  muscles  of 
the,  to  the  globe,  101 

motor  nerves  of  the,  98 

muscles  which  move  the,  101 

muscular  asthenopia  and  insuffi- 
ciencies of  the,  108 

neuroses  of  the,  164 

spasmodic  diseases  of  the  muscles 
of  the,  110 

Facial  hemiatrophy,  progressive,  568 

hemihypertrophy,      progressive. 
569 

nerve,  anatomy  and  diseases  of 
the,  111 

palsies,  115 

spasm,  113 
Family  nervous  diseases,  326 
Faradic  medical  batteries,  70 
Fever,  hysterical,  498 
Fibres,  nerve,  9,  13 
Fibrillary  tremor,  33 
Fibroma  molluscum,  95 

of  the  brain,  456 
Fingers,  dead,  207 

in  writers'  cramp,  554 
Flechsig,  oval  zone  of,  216 
Fleece  of  the  cerebellum,  361 
Flexor  response,  47 
Flushing,  176 
Flute-players'  cramp,  557 
Focal  symptoms  of  brain  tumors,  448 
Foerster's  shifting  type,  524 


INDEX. 


621 


Forced  movements,  34 

Forearm,  cord  centres  for  muscles  of 

the,  227 
Fore-brain,  343 
Foot,  cord  centres  for  muscles  of  the, 

229 
Fractures,  spontaneous,  in  locomotor 

ataxia,  282 
Friedreich's  ataxia,  300 
Functional  nervous  diseases,  467 

Galvanic  batteries,  70 

Ganglia,  cerebral,  346 

Gangrene,  symmetrical,  205 

Gasserian  ganglion,  area  of  anaesthe- 
sia following  removal  of  the,  172 

GedveLst,  network  of,  11 

Gemmules   in    the   cerebellar  cortex, 
360 

General  paralysis  of  the  insane,  467 

Gerlier's  disease,  194 

Giddiness,  (90 

Glioma  of  the  brain.  455 
of  the  spinal  cord,  331 

Gliosis,  30 

Globus  hystericus,  489 

Glossopharyngeal  nerve,  anatomy  of 
the,  120 

diseases  of  the,    121 

sensory  neuroses  <>f  the,  194 
Olossoplegia,  129 
Goitre,  exophthalmic,  644 

s  cells.   8,   361 

Goll,  column  of,  214,  217,  219 
Gomhault,  triangli  of,  816 

■"it  I 
Gray  matter,  central,  16 

cortical,  17 
Gudden,  commissure  of,  168 
Gumma  of  the  brain,    171 

of  the  spinal  cord,  :>:fl 

1 1  \  i; ri    as  a    factor  in   the  etiology  of 

nervous  diseaa 
Haematomyelia,  239 
Hematorrhachis,  288 
Hsemidrosis,  definition  of,  ;'>s 
Hand,   cord    centres    for   muscles   of 

the  227 


Head,  cord  centres  for  muscles  of  the, 

222 
Headache,  176 

hydrotherapy  in,  599 

location  of  pain  in,  according  to 
the  cause,  179 

morning,  179 

sick,  181 

treatment,  612 
Hearing,  centres  for,  375 

hysterical  disturbances  of,  491 
Heat,  effects  of,  in  the  treatment  of 

nervous  disease-.  65 
Hemianopsia,  169 
Hemiatrophy,  lingual,  130 

progressive  facial,  568 
Hemicrania,  181 
Hemihypertrophy,  progressive  facial, 

569 
Hemiopic  pupillary  reaction.  170,  451 
Hemiplegia,  386,  425 

definition  of,  35 

hereditary,  326 

hysterical,  493 

infantile,  437 

hephastic,  .m? 
Hemorrhage,  cerebral,  422 

meningeal,  422,  423 

spinal,  238 
Henle,  sheath  of,  9 
Hepha?stic  hemiplegia,  557 
Hereditary  nervous  diseases.  826 
Heredity  in   the  etiology  <>)'  nervous 

diseases,  23 
Herpes,  170 

zoster,  199 
Heterophoria,  definition  of,  Kt'.t 

spinal,  237 
Biccough,  b'.- 
Hind  brain,  3 1 1 
Hutchinson  face,  ins 

pupil.   128 
Hydrocephalus,  acute.  897 

chronic,  '■>'■>'> 
II\  dromyelia,  838 
Hydrorrhachis  interna.  286 
Hydrotherapy  In  nervous  diseases  65 
597 

sedative.  (W 


622 


INDEX. 


Hydrotherapy,  tonic,  62 
Hygiene  of  the  nervous  system,  60 
Hyperacusis,  194 
Hyperemia,  cerebral,  405 

meningeal,  392 

spinal,  242 
Hyperesthesia,  auditory,  194 

definition  of,  36 

hysterical,  493 
Hyperalgesia,  definition  of,  36 
Hyperidrosis,  definition  of,  37 
Hyperkinesis,  32 
Hyperosmia,  162 

Hypertrophy,  pseudo-muscular,  321 
Hypnotism,  585 

lethargic,  586 

major,  586 

minor,  585 
Hypoglossus  nerve,  anatomy  of  the, 
128 

motor  neuroses  of  the,  129 
Hypophysis,  cerebral,  tumors  of  the, 

453 
Hysteria,  487 

amnesia,  499 

amyosthenia,  494 

anaesthesia,  491 

aphonia,  494 

blue  oedema,  498 

catalepsy,  499 

cerebral  automatism,  499 

contractures,  495 

convulsions,  489,  490,  501 

diagnosis,  500 

etiology,  487 

fever  in,  498 

globus,  489 

hearing  in,  491 

hydrotherapy  in,  599 

hyperesthesia,  493 

major,  489 

mental  state  in,  496 

minor,  488 

motor  symptoms,  493 

neuralgia,  493 

paralyses,  493 

pathology,  500 

prognosis,  501 

sensory  symptoms,  490 


Hysteria,  stigmata,  409 

suggestibility  in,  497 

symptoms,  488 

of  the  crises,  489 
of  the  interparoxysmal  state, 
490 

taste  disturbances  in,  492 

trance,  499 

treatment,  501,  608 

tremor  in,  495 

trophic  disorders,  497 

vasomotor  symptoms,  498 

viscera,  symptoms,  497 

visual  disturbances  in,  491 
Hystero-epilepsy,  498 
Hystero-neurasthenia,  529 

Idiocy,  hereditary  amaurotic,  326 

Ignipedites,  90 

Impotence,  hydrotherapy  in,  600 

treatment,  608 
Incontinence  of  urine,  hydrotherapy 

in,  600 
Infantile  spinal  paralysis,  261 
Infection  as  a  factor  in  the  etiology 

of  nervous  diseases,  26 
Inflammation,  classification  of,  28 

exudative,  28 

of  nervous  tissue,  27 

productive,  28 
Insomnia,  578 

treatment,  608 
Insufficiencies,  muscular,  of  the  eye, 

108 
Intention  tremor,  33 
Intercostal   nerves,  sensory  neuroses 

of  the,  198 
Iridoplegia,  106 
Irritability  of  a  nerve,  21 
Irritation,  spinal  531 
Isthmus,  344 

Jumpers,  503 

Kakke,  90 

Karyochromes,  7 
Katatonia,  589 
Knee  jerk,  48 

Lacrymation,  176 


INDEX. 


623 


Laryngeal  epilepsy,  syncope,  or  ver- 
tigo, 194 
Larynx,  chorea  of  the,  503 
Latah,  503 

Latent  regions  of  the  brain,  377,  379 
Lateral  sclerosis,  295 

amyotrophic,  318 
Lead  palsy,  141 
Leg,  cord  centres  for  muscles  of  the, 

229 
Leptomeningitis,  cerebral,  393 

lumbar  puncture  in,  394 

spinal,  acute,  245 
chronic,  247 
Lethargic  hypnotism,  586 
Lethargy,  589 

Levator  palpebral,  spasm  of  the,  110 
Lewis,  scavenger  cells  of,  14 
Lighl  reflex,  51 
Lisping,  129 
Lissauer's  column,  211 
Little's  disease,  295,  442 
Localization,  cerebral,  372 

spinal,  222 
Lockjaw,  111 
Locomotor  ataxia,  274 

arthropathies  of,  281 

ataxic  stage,  275 

brain  symptoms  in,  284 

complications,  284 

course  of,  284 

crises  in,  2H3 

definition,  274 

diagnosis,  291 

etiology,  274 

exercise  treatment  of ,  CIO 

eye  symptoms  of,  279 

forms,  274 

fractures  in,  282 

gait  in,  277 

gastric  crises  of,  283 

hearing  in.  279 

hydrotherapy  in.  599 

initial  stage,  278 

joint  affections  in,  281 

laryngeal  crises  in,  283 

muscular  atrophies  in,  283 

neuralgia  in,  ■.■; ; 
optic  atrophy,  279 


Locomotor  ataxia,  pains  in,  277 

paralytic  stage,  276 

patellar-tendon  reflex  in,  277 

pathological  anatomy,  285 

pathology,  288 

prognosis,  291 

sexual  power  in,  284 

skin  disorders  in,  283 

spot  pains  in,  277 

symptoms,  275 

syphilis  in  the  etiology  of,  274, 
291 

treatment,  292,  609 

trophic  disturbances  in,  283 
Lumbar  nerves,  anatomy  of  the,  148 
motor  neuroses  of  the,  149! 
sensory  neuroses  of  the,  200 
Luys'  body,  358 

Marie's  disease,  569 
Massage  in  the  rest  treatment,  603 
in  the.  treatment  of  nervous  dis- 
eases, 65 
Mastodynia,  199 
Masturbation,  540 
treatment,  611 
Mechanisms  of  the  nervous  system, 

20 
Median  nerve,  paralysis  of  the,  144 
Medulla  oblongata,  functions  of  the, 
379 
position  of  the  cranial  nuclei  in 

the,  112 
tumors  of  Hie,  452 
Medullary  sheath,  11 
Memories,  centres  for,  376 
Meniere's  disease.    190 

Meninges,  cerebral,  :!ii<> 

anaemia  of  the,  392 
blood  supply  of  the,  368 
diseases  of  the.  392 
functions  of  the.  807 
hemorrhage  in  the,  122,  423 

hyperemia  of  the,  392 

spinal,  208 

hemorrhage  in  the.  238 
inflammation  of  the,  243 
Meningitis,  alcoholic,  401 

ei  rebral.  892 


624 


INDEX. 


Meningitis,  epidemic  cerebro-spinal, 
395 

external  cerebral,  392 
spinal,  243 

internal  spinal,  244 

lepto,  245,  393 

lumbar  puncture  in,  611 

pachy-,  243,  392 

serous,  401 

spinal,  243 

tuberculous,  397 
Meningocele,  cerebral,  392 

spinal,  236 
Meningo-myelitis,  247 
Meningo-myelocele,  236 
Melalgia,  154,  200 
Mesencephalon,  3,  344 
Mesocephalic,  definition  of,  42 
Metencephalon,  3,  344 
Micrencephaly,  390 
Microcephaly,  390 
Micromyelia,  238 
Mid-brain,  344 
Migraine,  181 

fulgurating,  182 
Milkers'  spasm,  557 
Milliampere,  definition  of,  68 
Milliamperemeter,  69 
Miners'  nystagmus,  110 
Monoplegia,  definition  of,  35 
Monroe,  fissure  of,  morphological  im- 
portance of,  345 
Morton's  neuralgia,  204 
Morvan's  disease,  146 
Motility,  disordered,  examination  for, 

44 
Motor  tracts  in  the  brain,  362 
Movements,  Fraenkel's,  in  the  treat- 
ment of  nervous  diseases,  66 
Mucous  enteritis,  528 
Multiple  neuritis,  85,  see  Polyneuritis 
Multiple  sclerosis,  416 

aborted  types  of,  418] 
Muscles,   table  showing  innervation, 

functions,  etc.,  of  the,  222 
Muscular     asthenopia     and     insuffi- 
ciencies, 108 
Muscular  atrophy,  arthritic,  327 

hereditary  progressive,  327 


Muscular  atrophy,  hereditary,  of  leg 
type,  314 
infantile  progressive,  325 
occupation,  328 
progressive,  309 

spastic  form  of,  318 
Muscular    dystrophies,    progressive, 

320 
Musculo-spiral    nerve,    paralysis    of 

the.  141 
Musicians'  cramp,  556 
Myelencephalon,  3,  344 
Myelin  sheath,  11 
Myelitis,  249 
acute,  249 

definition,  249 
diagnosis,  253 
disseminated,  250.  256 
etiology,  250 
forms,  249 

pathological  anatomy,  252 
prognosis,  255 
symptoms,  250 
transverse,  249,  256 
treatment,  255 
annular,  definition,  249 
central,  symptoms,  258 
chronic,  256 

diagnosis,  259 

etiology,  256 

forms,  256 

pathology,  259 

prognosis,  259 

symptoms,  257 

syphilis  in  etiology  of,  256 

syphilitic    spinal     paralysis, 

257 
treatment,  260 
classification  of,  249 
compression,  definition.  249 

symptoms,  258 
diffuse,  definition,  249 
disseminated,  definition,  249 
hemorrhagic,  definition,  249 
marginal,  definition,  249 
periependymal,  definition,  249 

symptoms,  258 
purulent,  definition,  249 
septic,  definition,  249 


INDEX. 


625 


Myelitis,  syphilitic,  definition,  249 
transverse,  definition,  249 
tuberculous,  definition,  249 

Myoclonus  multiplex,  513 

Myoidema,  definition  and  significance 
of,  46 

Myospasia,  513 

Myotonia  congenita,  503 

Myriad) it,  503 

Myxcedema,  572 

Narcolepsy,  589 

Neck,  cord  centres  for  muscles  of  the, 

223 
Neck  pains,  196 
Necrosis,  coagulation,  29 
Nerve,  abducens,  anatomy  of  the,  99 
paralysis  of  the,  107 
acoustic,  anatomy  of  the,  186 

neuroses  of  the,  187 
afferent,  19 
anaemia  of,  79 
auditory,  anatomy  of  the,  186 

neuroses  of  the,  186 
brachial,  paralysis  of  the,  136 
cerebrospinal,   sensory  neuroses 

of  the,  152 
cervical,  motor  neuroses  of  the, 
132,  136 
sensory  neuroses  of  the,  196, 
197 
circumflex,  paralysis  of  the,  141 
cranial,  apparent  origin  of  the,  99 
sensory  neuroses  of  the,  159 
degeneration  of,  80 
diseases  of  special,  98 
dorsal,  anatomy  of  the,  147 

motor  neuroses  of  the,  147 
efferent,  30 
eighth,  anatomy  of  the,  186 

neuroses  of  the,  187 
electrical  currents  in,  travelling 

with  Impulses,  21 
eleventh,  anatomy  of  the,  122 
diseases  of  the,  123 

exdto  reflex,  19 

facial,  anatomy  of  the,  1 1 1 

diseases  of  the,  112 
fifth,  anatomy  of  the,  170 
40 


Nerve  fifth,  motor  neuroses  of  the, 
111 

sensory  neuroses  of  the,  170, 
173* 
fourth,  anatomy  of  the,  99 

paralysis  of  the,  107 
glossopharyngeal,    anatomy    of 
the,  120 

diseases  of  the,  121 

sensory  neuroses  of  the,  194 
hyperaemia  of,  79 
hyperplasia  of,  95 
hypertrophy  of,  95 
hypoglossus,  anatomy  of  the,  12S 

motor  neuroses  of  the,  129 
inflammation  of,  79,  see  Neuriti* 
inhibitory,  20 
intercostal,   sensory   neuroses  of 

the,  198 
lumbar,  anatomy  of  the,  148 

motor  neuroses  of  the,  149 

sensory  neuroses  of  the,  200 
median,  paralysis  of  the,  144 
motor,  20 
musculo-spiral,  paralysis  of  the, 

141 
ninth,  anatomy  of  the,  120 

sensory  neuroses  of  the,  194 
nuclei  of  origin  of,  78 
OCUlo-motor,  anatomy  of  the,  99 

paralysis  of  the,  104 
olfactory,  anatomy  of  the,  169 

neuroses  of  tin-,  161 
optic,  anatomy  of  the,  162 

diseases  of  the.  164 
origin  of,  78 

peripheral,  blood-vessels  of  the, 
15 

diseases  of  the,  78 
phrenic,  neuroses  of  the,  133 
pneumogastric,  anatomy  of  the, 

121 
posterior    thoracic,   paralysis   of 

the,  141 
regeneration  of,  83 
sacral,  anatomy  of  the,  149 

motor  neuroses  of  the,  150 

sensory  neuroses  of  the,  205 
sciatic,  neuralgia  of  the,  201 


626 


INDEX. 


Nerve,  secretory,  20 
sensory,  19 
seventh,  anatomy  of  the,  111 

diseases  of  the,  112 
sixth,  anatomy  of  the,  99 
special   sense,    neuroses   of    the, 

159 
spinal,  anatomy  of  the,  131 

motor  neuroses  of  the,  132 
spinal  accessory,  anatomy  of  the, 
122 
diseases  of  the,  123 
suprascapular,   paralysis  of  the, 

141 
sympathetic  of  the  eye,  paralysis 

of  the,  106 
syphilis  of,  458 
tenth,  anatomy  of  the,  121 
third,  anatomy  of  the,  99 
paralysis  of  the,  104 
thoracic,  anatomy  of  the,  147 
motor  neuroses  of  the,  147 
sensory  neuroses  of  the,  198 
trigeminus,  anatomy  of  the,  170 
motor  neuroses  of  the,  111 
sensory  neuroses  of  the,  173 
trochlear,  anatomy  of  the,  99 

paralysis  of  the,  107 
trophic,  20 
tumors  of,  '.)■"» 

twelfth,  anatomy  of  the,  128 
ulnar,  paralysis  of  the,  144 
vagus,  anatomy  of  the,  121 
Nerve  cells,  2,  5,  10 
body  of  the,  7 
central,  8 
connection  of,  with  nerve  fibres, 

13 
in  the  cord,  212 
nucleus  of  the,  7 
peripheral,  8 
physiology  of  the,  21 
processes  of  the,  5 
reproduction    of,  does  not   take 
place,  30 
Nerve  fasciculi,  9 
Nerve  fibres,  9 

connection  of,  with  nerve  cells,  13 
medullated,  11 


Nerve  fibres,  non-medullated,  11 

size  of,  12 
Nervous  diseases,  causes  of,  23,  60 

diagnosis  of,  39 

functional,  467 

symptoms  of,  31 

treatment  of,  60,  597 
Nervous  exhaustion,  519 
Nervous  system,  arrangement  of,  2 

blood-vessels  of  the,  15 

chemistry  of  the,  22 

histology  of  the.  5 

hygiene  of  the,  60 

mechanisms  of  the,  20 

neuronic  architecture  of  the,  1*5 

pathology  of  the,  27 

peripheral,  anatomy  of  the,  78 
divisions  of  the,  3 

physiology  of  the,  19 

sympathetic,  17 

ganglia  of  the,  4 
Neuralgia,  156 

cervico-biachial,  197 

cervico-occipital,  195 

congestive,  of  the  feet,  204 

epileptiform,  174 

Fothergill's,  174 

hysterical,  493 

in  peripheral  nerve  disease,  84 

intercostal,  198 

lumbo-abdominal,  200 

mammary,  199 

Morton's,  204 

plantar,  ^03 

red,  of  the  feet,  204 

sacral,  205 

sciatic,  201 

treatment,  612 

trigeminal,  173 
Neurasthenia,  519 

acquired,  522,  529 

angiopathie,  533 

climacteric,  522,  529 

course,  537 

diagnosis,  535 

etiology,  519 

forms  of,  522,  529 

gravis,  533 

hydrotherapy  in,  598 


INDEX. 


627 


Neurasthenia,  hystero-,  529 

pathogeny,  534 

pathology,  534 

primary,  522,  529 

prognosis,  5:;7 

spinal  irritation.  531 

symptoms,  523 

traumatic,  522,  529 

treatment,  538 

with  fixed  idea.  532 
Neuraxon,  5,  11,  16 

cellulipetal  impulses  in  the,  16,  17 
Neurilemma,  11 
Neuritis.  79 

ascending,  80 

brachial,  140 

complicating  forms  of,  94 

degenerative,  80 

dermatitic,  199 

descending,  80 

diffuse,  80 

disseminated,  80 

interstitial,  79 

migrating,  80,  145 

multiple,  85,  see  Polyneuritis 

peri-.  79 

retrobulbar,  166 

segmental,  80 

trional,  cause  of,  87 

ulnar,  145 
Neuro-fibromata,  plexiform,  95 
Neuroglia,  13 
Neuromata,  95 
Neurons,  2,  5,  16 

collaterals  of  the,  6 

commissural,  20 

diai: ram    showing    the  arrange 
mi m  of  the,  18 

end  brush,  6 

independence  of  the  individual. 
7,  16 

intercentral,  20 

terminal  arborization,  6 
Neuro  retinitis,  164 
Neuroses,  acquired,  507 

anxiety,  582 

definition  of,  :!l 

degenerative,  474 

functional,  Wt 


Neuroses,  occupation,  551 

professional,  551 

secretory,  37 

sexual,  540 

traumatic,  529,  543 

trophic,  568 

vasomotor,  568 
Nictitating  spasm,  115 
Nightmare,  582 
Night  terrors,  583 
Nose,  neuroses  of  the,  161 
Nuclein,  22 

Numbness,  waking,  154 
Nyctalopia,  169 
Nystagmus,  110 

Occupation-  as  a  factor  in  the  etiol- 
ogy of  nervous  diseases,  25 
Occupation  neuroses,  551 
Ocular  hyperesthesia,  168 
Oculo-motor  nerve,  anatomy  of  the, 
99 

paralysis  of  the,  1 04 
(Edema,  angio-neurotic,  575 

blue,  of  hysteria,  498 

circumscribed,  575 
Ohm,  definition  of,  68 
Ohm's  law,  68 
Olfactory  nerve,  anatomy  of  the,  159 

neuroses  of  the,  161 
Olivary  bodies,  functions  of  the,  :!79 
Onanism,  540 
Operculum,  350 
Ophthalmoplegias,  104 

partial,  in   myasthenic  paralysis, 
108 

progressive,  107 

Optic  atrophy,   107 

in  locomotor  ataxia,  279 
optic  chiasm,  168 
Optic  nerve,  anatomy  <>r  the,  162 

diseases  of  the,  164 
Optic  thalami.  :!~>l 
Optic  tract.   163 
Orchil ic  extract  in  neurological  them 

peutics,  601 
Organic  extracts  in  neurological  thera 

peutics,  601 
Orthophoria,  definition  of,  109 


G28 


INDEX. 


Osteoarthropathy,  pneumogenic,  571 
Osteoma  of  the  brain,  556 

Pachymeningitis  externa,  cerebral, 
392 
spinal,  243 

hypertrophic,  244 

interna,  244 
Pack,  the  wet,  64 
Pain  palsy,  505 
Pain  sense,  testing  the,  55 
Pains,     lancinating,     of     locomotor 
ataxia,  277 
•neck,  196 

remedies  for  the  relief  of,  612 

side,  198 

spot,  in  locomotor  ataxia,  277 

transferred,  diagram  of  location 
of,  157 
Palate,  cord  centres  for  muscles  of 

the,  222 
Pallor,  176 
Palsy,  Bell's,  115 

bulbar,  progressive  upper,  107 

facial,  115 

night,  154 

shaking,  561 
Papillitis,  164 
Paradoxical  contraction,  51 
Paresthesia,  152 

aero-,  153 

cephalic,  153,  523 

definition  of,  37 

trigeminal,  176 
Parageusia,  195 
Paralysis,  abducens,  107 

acoustic,  187 

acute  ascending,  267 
atrophic,  261 

agitans,  561 

alcoholic,  85 

analgesic,  with  whitlow,  146 

arsenical,  85 

asthenic  bulbar,  316 
bulbospinal,  316 

birth,  441 

brachial,  136 

bulbar,  asthenic,  316 
progressive,  314 


Paralysis,  bulbo-spinal,  asthenic,  316 

cerebral,  of  children,  437 

compression,  141 

definition  of,  35 

diphtheritic,  85 

distribution  of,  from  injury  or 
disease  of  the  motor  nerves,  98 

divers',  240 

Erb's,  139 

facial,  115 

glosso-labio-laryngeal,  314 

hemiplegic,  421,  425 

hypertonic,  296 

hysterical,  493 

in  peripheral  nerve  disease,  84 

infantile  spinal,  261 

Landry's,  267 

lead,  141 

lingual,  129 

oculo-motor,  104 

of  the  ciliary  muscle,  106 

of  the  circumflex  nerve,  141 

of  the  diaphragm,  133 

of  the  iris,  106 

of  the  lumbar  nerves,  149 

of  the  median  nerve,  144 

of  the  musculo-spiral  nerve,  141 

of  the  phrenic  nerve,  133 

of  the  posterior  thoracic,  141 

of  the  sacral  nerves,  150 

of  the  spinal  accessory,  127 

of  the  suprascapular  nerve,  141 

of  the  sympathetic  nerves  of  the 
eye,  106 

of  the  ulnar  nerve,  144 

pain,  505 

progressive  bulbar,  314 

spastic  spinal,  295 

hereditary,  297,  327 

subacute  spinal,  266 

testing  for,  45 
Paramyoclonus  multiplex,  513 
Paramyotonia,  congenital,  505 
Paraphasia,  388 
Paraplasm,  7 
Paraplegia,  definition  of,  35 

hereditary  ataxic,  305,  327 

hysterical,  493 

senile,  266 


INDEX. 


629 


Paraplegia,  spastic  cerebral,  442 

tetanoid,  295 
Paresis,  definition  of,  35 
Paresis,  general,  467 

alcoholic  pseudo-paresis,  471 

definition,  467 

delusions  of  grandeur,  469 

dementing  type,  471 

etiology,  467 

excited  type,  468 

hypochondriacal  type,  470 

megalomania,  469 

pathology,  472 

prognosis,  472 

symptoms,  468 

syphilitic  pseudo-paresis,  471 

treatment,  478 
Paridrosis,  definition  of,  37 
Parkinson's  disease,  561 
Parosmia,  162 
Patella-tendon  reflex,  48 
Pathology,   general,    of   the   nervous 

system.  27 
Pavor  aocturnus,  583 
Perineurium,  10 

Peripheral  nerves,  diseases  of  the,  78 
Pernicious  anaemia,  combined   spinal 

scleroses  of.  29!) 
Pharynx,  cord  centres  for  muscles  of 

tlie.  222 
Phrenic  nerve,  neuroses  of  the,  133 
Physiology,  general,  of  the  nervous 

system,  19 
Pia  mater,  cerebral,  367 

inflammation  <>t  the.  893 

spinal.  'Jos 

inflammation  of  the,  345 
Pianists'  cramp.  556 
Pineal  gland,  tumors  of  the,  151 
Plexus,  brachial,  anatomy  of  the,  135 
Plexuses,  vascular,  of  the  spinal  cord. 

2:52 
Pneumogastric    nerve,    anatomy    of 

the.  L21 
Pnenmogenic  osteo  arthropathy,  571 
Poisoning  as  a   factor  in   the  etiology 

of  nervous  diseases  26 
Policeman's  disease,  205 

Polioencephalitis.  262 


Polioencephalitis,  acute,  413 
Poliomyelitis,  acute  anterior,  261 

chronic  anterior,  266 
Polyasthesia,  definition  of,  55 
Polyneuritis,  85 

acute  pernicious,  90 

complicating  forms,  94 

diagnosis,  93 

diphtheritic  neuritis,  88 

endemic  type,  90 

epidemic  type,  90 

etiology,  86 

forms  of,  85 

malarial,  90 

motor  type  of,  85 

pathology,  91 

prodromes,  87 

prognosis,  93 

pseudo-tabetic  type,  89 

sensory  type,  89 

symptoms,  88 

treatment,  94,  611 
Pons  Varolii,  functions  of  the,  379 

hemorrhage  in  the,  429 

nuclei  of  the,  358 

tumors  of  the,  452 
Porcncephalus,  439 
Posterior  thoracic  nerve,  paralysis  of 

the,  141 
Post-syphilitic     degenerative     proc- 
esses, 462 
Potential,  difference  in,  defined.  67 
Praedormitium,  disorders  of  the.  591 

Pressure  sense,  testing  the.  54 
Professional  neuroses.  551 
Projection  system  of  the  brain,  362 
Prosencephalon,  3 
Prosopalgia,  174 
Protogon,  22 

Protoplasm  of  the  nerve  cell.   T 

Pseudo-muscular  hypertrophy,  321 

Pseudo  tabes.  89 

Psychical   epileptic  equivalent,  475, 

177 
Psychosis,  definition  of,  :!l 

sexual,   540 

traumatic,  529,  543 

PtoMS,    104 

waking,  106 


630 


INDEX. 


Pupil,  Argyll  Robertson,  51,  170 

bemiopic    reaction    of    tbe, 

170,  4!)  I 
in  locomotor  ataxia,  280 
Hutchinson,  428 

reflex,  shutter  for  testing  the,  105 
Purkinje's  cells,  359 

PiACHiscHisrs  posterior,  235 
Railway  spine,  543 
Ranvief,  nodes  of,  11 
Raynaud's  disease,  205 
Reaction  at  a  distance  in  nerve  degen- 
eration, 81 

electrical,  diagnostic  table  of,  76 

of  degeneration,  74 

time,  22 
Red  nuclei  of  the  brain,  358,  378 
Re-enforcement  of  the  knee  jerk,  50 
Reflex  action,  21 

Reflex  causes  of  nervous  diseases,  26 
Reflexes,  35 

deep,  48 

examination  of  the,  47 

skin,  47 

superficial,  47 

tendon,  48 
Reil,  island  of,  349 
Remak,  fibres  of,  11 
Rest  treatment,  602 

partial,  605 
Retina,  anatomy  of  the,  162 
Retinal  hyperesthesia,  168 
Rheostat,  definition  of,  69 
Rhinencephalon,  159 
Rhombencephalon,  3 
R  L  8  people,  129 

Rolando,  gelatinous  substance  of,  212 
Rumpf's  symptom,  513 

Sacral  nerves,  anatomy  of  the,  149 
motor  neuroses  of  the,  150 

sensory  neuroses  of  the,  205 
St.  Vitus'  dance,  507 
Salivation,  176 
Saltatory  spasm,  514 
Sarcoma  of  the  brain,  456 
Scavenger  cells  of  Lewis,  14 
Schmidt,  incisures  of,  11 


Sehultze,  comma  of,  216 
Schwann,  sheath  of,  11 
Sciatica,  201 

treatment,  612 
Scleroses,    combined,    of    the    spinal 
cord,  298 
lateral  spinal,  295 

amyotrophic,  318 
multiple,  416 

aborted  types  of,  418 
of  nervous  tissue,  29 
of  the  spinal  cord,  270 
Putnam's  type  of  combined  spi- 
nal, 299 
Senile  paraplegia,  266 
Senility,  nerve  degeneration  in,  95 
Sensations,    cutaneous,    methods    of 
testing  the,  53 
delayed,  37 

disorders  of,  examination  for,  52 
referred,  37 
reflex,  37 

time  for  perceiving,  55 
transferred,  37 
Senses,  special,  centres  for,  374 

neuroses   of   tbe   nerves    of, 
159 
Sensori-motor  area  in  the  brain,  372 
Sensory  tracts  in  the  brain,  364 
Sewing-spasm,  557 
Sex  as  a  factor  in  the  etiology  of  ner- 
vous diseases,  25 
Sexual  neuroses  and  psychoses,  540 
Shaking  palsy,  561 
Shingles,  199 
Shock  as  a  factor  in  the  etiology  of 

nervous  diseases,  25 
Shoulder  and  upper  extremity,  cord 

centres  for  muscles  of  the,  224 
Shower  baths  in    the    treatment  of 

nervous  diseases,  62 
Side  pains,  198 
Singultus,  133 
Sinuses,  cerebral,  371 
Skin,    distribution    of     the     sensory 
nerves  of  the,  56 
reflexes,  47 
Skull,  dimensions  and  shape  of  the, 
42 


INDEX. 


61 


Skull,    landmarks  of  the,   indicating 
the   underlying    parts   of   the 
brain,  592 
Sleep,  accidents  of,  591 
disorders  of,  577 

the  praedormitium,  591 
morbid,  from  organic  disease,  578 
morbidly  deep,  570 
normal;  578 
paroxysmal,  589 
perversions  of,  581 
Sleep-drunkenness,  583 

Sleep  epilepsy.   589 
Sleeping-sickness,  591 
Smell,  centres  for,  376 

disorders  of,  101 
Smiths'  spasm,  557 
Somatochromes,  7 
Somnambulism,  584 
Somnolentia,  583 
Spasm,  facial,  113 

lingual,  \-l(.) 

nictitating,  115 

nodding,  1-7 

ocular,  110 

oscillating,  127 

Balaam,  127 

saltatory,  514 

winking,  115 
Spasmodic  tics.  503 
Spasmus  nutans.  127 

ic  spinal  paralysis,  295 

hereditary,  '397.  327 
special  senses,  centres  for,  374 
Spermatorrhoea,  540 

li\  drotherapy  in,  599 
Spider  cells,  18 
spina  bifida,  285 
Spinal  accessory  nerve,  anatomy  and 

diseases  of  11:  !,    1  22,    128 

Spinal  cord,  acute  softening  of  the, 
249 
amyotrophic  lateral  sclerosis,  318 

anaemia  of  the,  .'  18 

anatomy  of   the,  208 

anterolateral  ascending  tract,  220 
arteries  of  the,  229 
as\  mmet  iv  of  the,  238 

automat  ic  centres.  220 


Spinal  cord,  blood-supply  of  the,  229 
cavities  in  the,  333 
central  canal,  212 

double,  238 
centres  in  the,  220 
columns  of  the,  210,  212,  215,  218 
combined  scleroses  of  the,  298 
composition  of  the,  2l0 
degeneration    of   the,     primary, 
270 

secondary,  272 

short  tracts  of,  "273 
diseases  of  the,  234 

meninges  of  the,  243 
double,  238 
fissures,  210 
functional    disturbances   of    the, 

338 
gray  matter  Qf  the,  211 
hemorrhage  in  the,  238 
hemorrhagic  cavities  in  the,  333 
horns  of  the,  211,  220 
hyperaemia  of  the,  242 
inflammation  of  the,  249,  see  .)///< 

litis 
levels  of  the  reflexes  in  the,  48 
localization  in  the,  222 
lumbar  puncture  of  the,  Gil 
meninges  of  the,  208 

inflammation  of  the,  2  18 
malformations  of  the,  285 
myelitic  cavities  in  t  he,  883 
nerve  roots,  "209 
paracentesis  of  the   dura    mater. 

Oil 
physiology  of  the,  2  is 

plexuses  of  the,  232 

pyramidal  tracts.  '.Ms 
relation-;  of  the  different  parts  of 
the,  to  the  peripheral  nerves. 

brain,  and  each  other.  216 
root  arteries  of  the,  '.': ■<» 
root  ganglia,  209 
spindle-shaped  cells.  220 
splitting  of  the,  288 
sclerosis  of  the,  270 

aim  otrophic  lateral.  818 

combined,  298 

lateral.  295 


632 


INDEX. 


Spinal  cord,  sclerosis  of  the,  Putnam's 
type  of  combined,  299 
posterior,  274 
primary,  270 
secondary,  272 
syphilis  of  the,  462,  468 
system  diseases  of  the,  235 
topography  of  the,  222 
tumors  of  the,  330 
veins  of  the,  232 
white  matter  of  the,  213 
Spinal  irritation,  531 
Spinal  nerves,  motor  neuroses  of  the, 

132 
Spine,  railway,  543 
Spongioblasts  of  Cajal,  9 
Spotted  fever,  395 
Stammering,  129 
Static  electrical  batteries,  69 
Status  epilepticus,  477 

vertiginosus,  191 
Stellwag's  symptom,  547 
Stereognostic  sense,  54 
Stigmata  of  degeneration,  41 
Stuttering,  129,  133 
Substantia  nigra,  357 
Subthalamus,  358 
Suggestion,  585 
Suprascapular  nerve,  paralysis  of  the, 

141 
Suspension  in  neurological  therapeu- 
tics, 601 
Sympathetic  nervous  system,  17 

ganglia  of  the,  4 
Symptoms,  cerebral,  of  nervous  dis- 
ease, 32 
general,  of  nervous  disease,  31 
mental,  of  nervous  disease,  32 
motor,  of  nervous  disease,  32 

examination  for,  44 
secretory,  of  nervous  disease,  37 
sensory,  of  nervous  disease,  36 

examination  for,  52 
vasomotor,   of    nervous    disease, 
37 
Syncope,  laryngeal,  194 

local,  of  the  extremities,  207 
Syphilis  of  the  nervous  system,  460 
cause  of  internal  meningitis,  244 


Syphilis,  degenerative  processes  fol- 
lowing, 462 

hereditary,  464 
Syphiloma  of  the  brain,  454 
Syringomyelia,  334 

neuritic  type  of,  146 
Syringomyelocele,  236 

Tabks    dorsalis,    274,    see  Locomotor 

Ataxia 
Tabes,  pseudo-,  89 
Tachycardia  in  Graves'  disease,  546 
Tactile  sense,  testing  the,  53 
Tarsalgia,  205 
Taste,  centres  for,  376 

disorders  of,  194 

fibres  of  the  facial  nerve,  112 
of     the     glosso-pharyngeal 
nerve,  120 

hysterical  disturbances  of,  492 
Telegraphers'  cramp,  557 
Telencephalon,  3,  343 
Temperature  sense,  testing  the;  54 
Tendon  reflexes,  48 
Tension,  electrical,  defined,  67 
Testicle  extract  in  neurological  thera- 
peutics, 601 
Tetanilla,  515 
Tetanoid  paraplegia,  295 
Tetanus,  514 
Tetany,  515 
Thalamus  opticus,  377 
Therapeutics,  neurological,  597 
Thermoanesthesia,  definition  of,  36 
Thigh,  painful,  200 
Thomsen's  disease,  503 
Thoracic   nerves,    anatomy    of    the, 
147 

motor  neuroses  of  the,  147 

sensory  neuroses  of  the,  198 
Thrombosis,  cerebral,  434 
Thyroid  therapy,  601 
Tic  coordine,  512 

de  pensee,  503 

douloureux,  174 
treatment,  613 

mimic,  113 

spasmodic,  503 
Tinnitus  aurium  aut  cerebri,  187,  188 


INDEX. 


6! 


Tongue,  cord  centres  for  muscles  of 
the,  222 

hemiatrophy  of  the,  130 

paralysis  of  the.  129 

spasms  of  the,  129 
Topography,  craniocerebral,  592 
Torticollis,  123,  132 
Toxic  factors  in  the  etiology  of  ner- 
vous diseases,  26 
Trance,  589 

coma,  585 

hysterical,  499 

somnambulistic,  585 
Trauma  as  a  factor  in  the  etiology  of 

nervous  diseases,  25 
Traumatic   neuroses  and   psychoses, 

529,  543 
Treatment  of  nervous  diseases,  597 
Tremor,  33 

convulsive,  513 

hysterical,  495 

intention,  33 

of  paralysis  agitans,  563 

testing  for,  45 
Trigeminus  nerve,  anatomy  of    the, 
170 

motor  neuroses  of  the,  111 

sensory  neuroses  of  the,  173 
Trismus,  111 

Trochlear    nerve,    anatomy    of   the, 
99 
paralysis  of  t lie,  107 
Trophoneuroses.  658 

definition  of,  37 

peripheral,  205 
Trousseau's  symptom,  517 
Tubercula  dolorosa,  96 
Tuberculosis,  meningeal,  397 

of  the  brain.  451 
Tumors,  cerebral,  445 

focal  symptoms  of,  448 
'Tween -brain,  344 

1'lnak     nerve,     paralysis     of     the. 
144 


Ulnar   neuritis,   symmetrical    sponta- 
neous, 145 

Vagus  nerve,  anatomy  of  the.  121 
Vasomotor  neuroses,  peripheral,  205 
Veins,  cerebral,  370 
Vermis  of  the  cerebellum.  35H 
Vertigo,  189,  190 

arterio  sclerotic,  192 

auditory,  191 

bilious.  191 

laryngeal,  194 

lithamric,  191 

mechauical,  192 

neurotic,  191 

ocular,  192 

paralyzing,  194 

psychical,  192 

senile,  192 

stumbling,  192 
Vibratory  therapeutics,  601 
Violinists'  cramp,  557 
Vision,  centres  for,  374 

double,  103 

hysterical  disturbances  of,  491 
Volt,  definition  of,  68 
Von  Graefe's  symptom,  536 

Watchmakers'  cramp,  558 

Water,  uses  of,  in   the   treatment  of 
nervous  diseases,  62,  597 

Watt,  definition  of,  68 

Weir  Mitchell  treatment.  605 

Wernicke's  hemiopic  pupillary  reac- 
tion, 170,  451 

Wet-brain,  401 

Whitlow,    analgesic    paralysis   with, 
146 

Winking  spasm,  115 

Word  blindness,  387 
deafness,  387,  389 

Wristdrop,  141 

Writers'  cramp,  557 
treatment,  558 

Wryneck.  123.  132 
treatment,  612 


,i 


I 


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